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ATLAS AND EPITOME 

OF TRAUMATIC 

Fractures and Dislocations 



BY V 

PROF. DR. H. HELFERICH 

Professor of Surgery at the Royal University, Greifswald, Prussia 

AUTHORIZED TRANSLATION FROM THE GERMAN 

EDITED BY 

JOSEPH C. BLOODGOOD, M.D. 

Associate in Surgery, Johns Hopkins University, Baltimore, Md. 



ffiftb jEDttion, IRexuseD anD lEnlavQeb 



With 216 Colored Illustrations on 64 Lithographic Elates, and 
190 Figures in the Text 



PHILADELPHIA AND LONDON 

W. B* SAUNDERS & COMPANY 
1902 




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Copyright, 1902, by W. B. SAUNDERS & COMPANY. 



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EDITORIAL NOTE 



An American edition of this " Atlas of Fkactures 
and Dislocations/' translated from the fifth German 
edition, is needed and will be welcomed by both students 
and practitioners. 

Fractures and dislocations cannot be properly taught 
nor understood without illustrations showing the visible 
external deformity, the X-ray shadow, the anatomic prepa- 
ration, and the method of dressing. These are as necessary 
here as with anatomy. 

The book of Professor Helferich, better than any yet 
published, answers the requirements for illustrations. We 
have much to thank the author for. Such a splendid col- 
lection of illustrations is possible only in a very large 
clinic, and represents time, labor, and great care. The 
work has been reviewed with pleasure and profit. 

Jos. C. Bloodgood. 

Baltimoke, June, 1902. 



PREFACE TO THE FIFTH EDITION 



The present edition has been enriched by the addition 
of nine skiagraphs and twenty-one text figures. The text 
of the epitome has been enlarged and corrected. The 
original intention of retaining the character of an epitome, 
and describing important matters more fully at the expense 
of questions of great rarity, has been adhered to. Ac- 
cordingly, I refrained from inserting, from the wealth of 
my skiagraphs, reproductions of rare conditions. On the 
other hand, the reader will find many new Rontgen-ray 
pictures illustrating the commoner fractures. To assist in 
the understanding of the Rontgen-ray plates, — and I have 
no doubt many think this a very difficult matter, — I have 
taken skiagraphs of normal joints and added an explan- 
atory outline sketch carefully prepared by Dr. Werner. It 
is to be regretted that we do not as yet possess any method 
of reproduction which would enable us to present pictures 
approaching in excellence the Rontgen-ray plates. Many 
of the Rontgen-ray pictures were reproduced directly from 
original plates of larger size (as, for instance, the nine 
plates representing normal structures, Plate 6, and text- 
figures 97, 105, 106, 156, 157, and 158). Others were 
reproduced from drawings by Dr. Werner, copied from 
original plates and photographs. These are Plate 7, and 

the text-figures 2, 3, 66, 76, 80, 82, 87, 90, and others. 

5 



o PREFACE TO THE FIFTH EDITION 

I trust the book will be found useful in the study of 
fractures. I earnestly request the reader not to neglect 
either the text or the explanations of the plates, and to 
read with the corresponding parts of the skeleton in his 
hand. Both in the general and in the special portion of 
the book I have endeavored to present as complete a view 
of each case as possible, and to equip the physician for the 
manifold appearances that he will meet with in practice. 

Dr. Helferich. 



EXTRACT FROM THE PREFACE TO 
THE FIRST EDITION 



This "Atlas and Epitome" is intended to facilitate the 
student's introduction to the important department of frac- 
tures and dislocations, and to serve as a ready reference- 
book for the use of physicians in general practice. I have 
endeavored to make the book one of practical utility, and 
at the same time to elucidate some of the more important 
questions, especially those connected with the anatomy of 
fractures. 

The first suggestion for the book came through the pub- 
lisher, and I was glad to agree to his proposition. I wel- 
comed the opportunity to use the specimens and drawings 
which I had collected in the course of years, and I was 
glad also of the chance to contribute something to the 
general diffusion of useful knowledge in a department of 
medicine in which much harm can be done, and which has 
of recent years acquired great importance for the entire 
body of physicians. 

It is distinctly emphasized that this book is in no sense 
intended as a substitute for clinical studies or special 
courses, and can only serve to complete and illustrate the 
demonstrations and explanations of the clinical teacher. 

Part of the specimens were artificially produced and 
prepared. It has been my custom for some years, in con- 



8 EXTRACT FROM THE PREFACE TO THE FIRST EDITION 

nection with my course of operative surgery, to produce 
the more important injuries on the cadaver. Many of the 
plates and figures represent specimens which I had occa- 
sion to study when I acted as assistant to Herr Geheimrat 
Thiersch in the Leipziger Klinik, and later in Munich and 
at this place ; others belong to the pathologic anatomic 
collections in Munich and Greifsw r ald, and were kindly 
placed at my disposal by Professor Bollinger during his 
incumbency, and more recently by my colleague, Professor 
Grawitz. 

The present epitome arose out of my desire to perfect 
the explanations accompanying the plates, which did not 
seem to me quite sufficient. The various divisions of the 
Atlas are immediately followed .by corresponding portions 
of the epitome. Injuries of common occurrence and prac- 
tical importance are described in detail, while rare ones are 
described with a few words. 

Dr. Helfep.ich. 



CONTENTS 



PAGE 

I. General Considerations 17 

Fractures 17 

Varieties of Fractures . v 21 

Symptoms of a Recent Fracture 32 

The Examination of a Fracture 37 

The Diagnosis of Fracture 42 

Clinical Course and Repair of Fractures 43 

Complications of Fractures and Their Treatment ... 49 

Prognosis of Fractures 59 

Treatment of Fractures 62 

Dislocations 77 

II. Fractures of the Skull 84 

(A ) Fractures of the Skullcap 85 

(B) Fractures of the Base of the Skull 90 

III. Injuries of the Facial Bones 102 

Dislocations of the Lower Jaw 105 

(A) Forward Dislocations 105 

(B) Backward Dislocations 107 

IV. Fractures and Dislocations of the Vertebral Column 109 

(A) Fractures of the Vertebral Column 109 

1. Fracture of the Body of a Vertebra 109 

2. Fractures of the Vertebral Column or Spinous Pro- 

cesses 120 

(B) Dislocations of the Vertebral Column 120 

V. Fractures of the Thorax 123 

(A) Fractures of the Ribs 123 

(B) Fractures of the Sternum 125 

9 



10 CONTENTS. 

PAGE 

VI. Fractures and Dislocations of the Upper Extrem= 

ity 126 

1. Clavicle 127 

(A) Fracture of the Clavicle 127 

(B) Dislocations of the Clavicle 135 

2. Scapula 137 

3. Shoulder-joint 139 

4. Humerus 154 

(A) Fractures of the Upper End of the Humerus . . . 154 

(B) Fractures of the Shaft of the Humerus 165 

(C) Fractures of the Lower End of the Humerus . . . 171 

5. Elbow . . • . . . 187 

(A) Dislocations 187 

(B) Intra-articular Injuries 195 

6. Forearm 196 

(A) Fracture of Both Bones of the Forearm 196 

(B) Fractures of the Ulna 204 

(C) Fractures of the Eadius 212 

(D) Dislocation at the Lower Articulation of the Ulna 227 

7. Wrist-joint .227 

8. Hand and Fingers 228 

(A) Fractures 228 

(B) Dislocations 231 

VII. Fractures and Dislocations of the Lower Extrem= 

ity 238 

1. Pelvis . , 238 

2. Hip-joint , . 244 

(A) Backward Dislocation 245 

(B) Forward Dislocation 251 

(C) Rare Dislocations of the Hip-joint 253 

3. Femur 253 

( A) Fractures of the Upper End of the Femur .... 253 

(B) Fracture of the Shaft of the Femur 271 

(C) Fractures of the Lower End of the Femur .... 284 

4. Knee-joint 287 

(A) Dislocation of the Knee-joint 287 

(B) Dislocations of the Patella 289 

(C) Fractures of the Patella 290 

(D) Other Intra-articular Injuries of the Knee-joint . . 302 



CONTENTS. 11 

PAGE 

5. Leg , 305 

(A) Fracture of the Leg at the Upper End 305 

I. Isolated Fractures at the Upper End of the Tibia 305 

II. Isolated Fracture at the Upper End of the Fibula 308 

(B) Fracture in the Middle Portion of the Leg .... 309 

I. Fracture of Both Bones in the Eegion of the 

Diaphysis 309 

II. Isolated Fracture of the Shaft of the Tibia . . 316 

III. Isolated Fracture of the Shaft of the Fibula . 317 

(C) Fracture of the Lower End of the Leg 318 

I. Fracture of Both Bones at Their Lower Ends . 318 
II. Isolated Fracture of the Tibia at Its Lower 

Extremity 332 

III. Isolated Fracture of the Fibula at Its Lower 

Extremity 332 

6. Astragalo-crural Articulation . 333 

7. The Foot 335 

(A) Fracture of the Tarsal Bones 335 

(B) Dislocations of the Foot 343 



Index 345 



DESCRIPTION OF PLATES 



Plate 1. — Bending Fractures (Greenstick Fractures). 

Plate 2. — Torsion-fractures. 

Plate 3. — Fractures Produced by Compression, Tearing, and Crushing. 

Plate 4. — Gunshot-fractures. 

Plate 5. — Displacement of Fragments. 

Plate 6. — Fracture of the Fibula as shown by a Skiagraph. 

Plate 7. — Observation of the Repair of a Severe Fracture of the Leg 

by means of the Rontgen Rays. 
Plate 8. — Repair of Fractures; Callus-formation. 
Plate 9. — Fractures of the Vault of the Skull. 
Plate 10.— Gunshot Wound of the Skull. 
Plate 11. — Fracture of the Skullcap Continued to the Base. 
Plate 12. — Various Fractures of the Vault and Base of the Skull. 
Plate 13. — Fracture of the Base of the Skull by an Injury to the Nasal 

Region. 
Plate 14. — Fractures of the Base of the Skull by Compression of the 

Skull. 
Plate 15. — Fracture of the Skull with Laceration of the Middle Menin- 
geal Artery, the Line of Fracture Extending to the Base 

of the Skull. 
Plate 16. — Fractures of the Lower Jaw. 
Plate 17. — Anterior Dislocation of the Lower Jaw. 
Plate 18. — Fracture of the Cervical Portion of the Vertebral Column 

with Contusions of the Spinal Cord. 
Plate 19. — Double Compression-fracture of the Vertebral Column. 
Plate 20. — Dislocation in the Cervical Portion of the Vertebral 

Column. 
Plate 21. — Fractures of the Ribs. 

Plate 22. — Fracture of the Costal Cartilages and of the Sternum 

13 



14 DESCRIPTION OF PLATES. 

Plate 22a. — Normal Shoulder-joint of an Adult. (The Picture is Ex- 
plained by Fig. 35.) 

Plate 23. — Fracture of the Clavicle with Typical Displacement of the 
Fragments. 

Plate 24. — Dislocation of the Sternal Extremity of the Clavicle. 

Plate 25. — Upward Dislocation of the Acromial End of the Clavicle. 

Plate 26. — Fractures of the Scapula. 

Plate 27. — Subcoracoid Dislocation of the Humerus. 

Plate 28. — Subcoracoid Dislocation of the Humerus. Anatomic Speci- 
men. 

Plate 29. — Subcoracoid Dislocation of the Humerus. Anatomic Speci- 
men. 

Plate 30. — Method of Reducing Subcoracoid Dislocation of the 
Humerus. 

Plate 31. — Old Subcoracoid Dislocations with the Formation of a New 
Articular Surface on the Scapula, and Wearing Away 
of the Humerus. 

Plate 32. — Fracture of the Surgical Neck of the Humerus, with 
Marked Displacement of the Fragments and Abduction 
of the Arm. 

Plate 33. — Fractures of the Upper End of the Humerus. 

Plate 34. — Traumatic Epiphyseal Separation at the Upper End of the 
Humerus. 

Plate 35. — Fractures of the Humerus. 

Plate 35a. — Explanation: Normal Elbow of an Adult as seen in the 
Skiagraph. 

Plate 36. — Fractures of the Lower End of the Humerus. 

Plate 37. — Valgus and Varus Position of the Elbow after Fracture of 
the Lower End of the Humerus. 

Plate 38. — Backward Dislocations of the Forearm. 

Plate 39. — Outward Dislocation of the Forearm and Separation of 
the Internal Condyle. 

Plate 40. — Fractures through the Middle of the Forearm. 

Plate 41. — Various Fractures of the Forearm and Normal Epiphyseal 
Lines. 

Plate 42. — Fracture of the Olecranon and Coronoid Process. 

Plate 43. — Isolated Dislocation of the Head of the Radius with Frac- 
ture of the Upper Third of the Ulna; Marked Displace- 
ment of the Fragments. 

Plate 44. — Typical Fracture of the Lower Radial Epiphysis. 



DESCRIPTION OF PLATES. 15 

Plate 45. — Typical Fracture of the Lower End of the Radius (Colles , 

Fracture). 
Plates 46, 47. — Differential Diagnosis of Fractures and Dislocations of 

the Wrist. 
Plate 4?rt. — Skiagraph of a Normal Adult Wrist-joint ; Anterior Yiew. 
Plate 47ft. — Skiagraph of a Normal Adult Wrist-joint ; Lateral Yiew. 
Plate 48. — Typical Dislocation of the Thumb. 
Plate 49. — Fractures of the Pelvis. 
Plate 50. — Backward Dislocation of the Thigh. 
Plate 51, 52. — Various Typical Forms of Dislocation of the Thigh in 

Preparations and in the Living Subject. 
Plate 52rt. — Normal Hip-joint of a Lad Seventeen Years Old. 
Plate 53. — Intracapsular (Median) Fracture of the Neck of the Femur 

(Fractura Colli Femoris Medialis). 
Plate 54. — Extracapsular or Lateral Fractures of the Neck of the 

Femur (Fractura Colli Femoris Lateralis). 
Plate 55.— Outward Rotation of the Thigh in Intracapsular (Median) 

Fracture of the Neck of the Femur. 
Plate 56. — Various Fractures of the Femur. 

Plate 57. — Typical Deformity in Fracture of the Middle of the Femur. 
Plate 58. — Typical Displacement of the Fragments in Supracondylar 

Fracture of the Femur. 
Plate 59. — Fractures of the Lower End of the Femur. 
Plate 60. — Dislocation of the Patella. 
Plate 61. — Fracture of the Patella. 
Plate 62.— Fracture of the Patella. 

Plate 62a. — Skiagraph of a Normal Adult Knee-joint; Anterior View. 
Plate 62b. — Skiagraph of a Normal Adult Knee; Lateral View. 
Plate 63.— Fractures of the Tibia, 
Plate 64. —Fractures of the Leg. 
Plate 65. — Fractures of the Lower End of the Leg. 
Plate 66. — Typical Fracture of the Ankle (Pott's Fracture). 
Plate 67. — Fracture of the Ankle. 

Plate 61a. — Skiagraph of a Normal Ankle-joint; Anterior View. 
Plate 676. — Skiagraph of the Normal Astragalo-tarsal Articulation 

and Tarsus; Lateral View. 
Plate 68. — Dislocation of the Foot at the Astragalo-crura! Articula- 
tion. 



FRACTURES AND DISLOCATIONS 



I. GENERAL CONSIDERATIONS 

FRACTURES 

Fkactures may be divided into traumatic fractures, or 
those produced by external violence, and spontaneous frac- 
tures, or those in which the degree of external force that 
produced them would not be sufficient to cause a fracture 
in a healthy bone. 

Spontaneous fractures are attributable to a brittle con- 
dition of the bones, due, as a rule, to neoplasms, such as 
sarcoma, metastatic carcinomata, or echinococcus cysts ; 
to inflammatory disease of the bones, as osteomyelitis with 
insufficient osteosclerosis (involucra), bone abscess, tuber- 
cular caries, syphilis [gumma], rachitis [rare], or osteo- 
malacia ; to nutritive disturbances of the bone in diseases 
of the spinal cord, such as tabes and syringomyelia ; or to 
grave disturbances of metabolism, such as osteopsathyrosis 
(fragility of bone) in gout. The discussion of this class 
of fractures will not find a place in this work, which deals 
exclusively with traumatic fractures occurring in healthy 
bones. 

[Attention should be called here to the fact that not 
infrequently a fracture, usually associated with but slight 
trauma, may be the first sign of a medullary sarcoma. 
For this reason one should be very suspicious, especially 
in an adult, of a fracture following an unusually slight 
trauma. The question of diagnosis could probably be 
settled by an examination with the Rontgen ray. It is 
2 17 



18 FRACTURES AND DISLOCATIONS. 

also to be borne in mind that a fracture at the site of a 
medullary sarcoma may unite (Koenig). Personally I 
have never observed this to take place. 

Fractures in healed cases of osteomyelitis are not un- 
usual. In such instances the bone is weakened by the 
great increase of fibrous tissue, a condition called ostitis 
fibrosa (von Recklinghausen). Instead of a fracture there 
may be a bending of the bone. With proper treatment 
we may, however, expect firm union, although it is usually 
delayed, and for this reason the fracture dressing should 
be maintained for a longer period. 

The relation of contusion of the bone as an etiologic 
factor in pyogenic and tubercular osteomyelitis and prim- 
ary sarcoma is a very interesting one. Observation has 
demonstrated that these diseases very rarely follow a com- 
plete fracture, but are frequently associated with contusion 
of the bone with or without splintering. For this reason 
if the induration and swelling following a trauma of the 
bone do not disappear in the usual time, we should be 
suspicious of the onset of one of these diseases, and insti- 
tute an early investigation. — Ed.] 

Fractures are divided into compound [open] and simple 
or subcutaneous fractures. A compound fracture is one in 
which there is a simultaneous injury of the skin and soft 
parts at the seat of fracture. As a rule, this involves ex- 
posure of the seat of fracture to the air and to infection 
reaching it from without ; but even when the injury to 
the skin and soft parts is slight and does not communicate 
with the fractured bone, it is still spoken of as a com- 
pound fracture. In the treatment of such cases the 
strictest antisepsis or asepsis is to be observed in accord- 
ance with the accepted principles of surgery ; this offers 
the only prospect of a favorable course in compound frac- 
tures, which were formerly considered so dangerous. In 
other respects the treatment dores not differ from that of 
simple fractures, having for its aim the firm union of the 
fractured bone with the least possible amount of displace- 



GENERAL CONSIDERATIONS. Itf 

ment. This is, of course, a more difficult task in com- 
pound fractures, and the surgeon is often forced to be 
content with a more or less imperfect result. 

As we shall not return to the subject of compound frac- 
tures in this work, a few remarks on the treatment will 
be in order. If the compound fracture is not so severe as 
to require primary amputation of the limb, conservative 
treatment may be instituted. The first and most impor- 
tant indication in that case is to employ every means to 
render the wound aseptic. To this end the primary dress- 
ing should be applied as after an operation (even under 
full anesthesia if necessary). If the skin has merely been 
injured by a sharp fragment of bone piercing it from with- 
in, the case is much simpler, and a good result will usu- 
ally be obtained by disinfecting the wound and surround- 
ing skin, replacing the fragments of bone, and applying 
splints. Later a well-fitting plaster dressing may be sub- 
stituted, if necessary, under anesthesia. If, however, the 
skin has been injured by the external force which caused 
the fracture, with the production of an extensive contused 
and contaminated wound, all sinuses and pockets must 
be carefully laid open with the knife and, after thorough 
cleansing, packed with aseptic gauze; the mechanical treat- 
ment of such a fracture, which must be applied at the same 
time, is often very difficult. 

[The term compound or open fracture, I believe, should 
be strictly confined to one in which the skin wound com- 
municates with the seat of the fracture. Amputation 
should be the last resort. Every attempt should be made 
to save the limb. It should be decided at once whether 
an operation is indicated. In the treatment of compound 
fracture in which amputation is not indicated one should 
either do very little, or, if it is considered best to operate, 
the operation should be most carefully performed, with the 
most thorough surgical technic. In the first instance we 
decide against operative interference, because the wound is 
small, the laceration of the soft parts not extensive ; there 



20 FRACTURES AND DISLOCATIONS. 

is no nerve injured, no large hematoma. The fracture 
can be easily reduced, and there are no comminuted frag- 
ments which cannot be replaced, and we judge from the 
history of the accident and nature of the external wound 
that the degree of the infection has been slight. Here it 
is only necessary to disinfect the external wound, irrigat- 
ing it with a solution of 1 : 1000 bichlorid, or to swab it 
out with pure carbolic acid (Lister's method). 1 It is 
probably best not to completely close the external wound 
of the skin, because if there is much hemorrhage from the 
fracture the wound will act as a safety-valve, and there 
will be no distention of the tissues with blood which 
lowers their resistance to infection. In these cases if there 
is much discharge of blood, the dressing should be fre- 
quently changed, and the external surface of the wound 
and the skin redisinfected. The blood-clot, however, 
which will be found filling the external wound at the first 
dressing, should never be disturbed. These cases of com- 
pound fracture should run an almost afebrile course with 
less elevation of temperature than in a simple fracture, 
because in the latter the blood has no exit, and there is 
fever (100° to 102° F.) from the absorption of fibrin 
ferment, but associated with this fever no leucocytosis. 
Elevation of temperature and leucocytosis in a com- 
pound fracture should be considered an indication to open 
and disinfect the wound. In the second instance the indi- 
cations for operative interference in a compound fracture are 
numerous, the most important being thorough disinfection; 
the next, better reduction and fixation of the fragments. 
Either should be considered a sufficient indication. Great 
laceration of the soft parts, excessive hemorrhagic exudate 
or a hematoma, nerve or tendon injury, are other indica- 
tions. When we operate, it should be done with the most 
careful tech nic and the best possible surroundings. In the 
majority of instances a patient with a compound fracture 
would have a better chance of recovery without operation 
1 See Progressive Medicine for December, 1901, p. 271. 



GENERAL CONSIDERATIONS. 21 

if the operation could not be done in a proper and thor- 
ough manner. In the operation, after the thorough disin- 
fection of the skin and external wound, the wound should 
be enlarged, disinfecting as we proceed. In approaching 
the bone, the greatest care should be taken not to disturb 
the periosteal attachments of the fragments. Only those 
fragments should be removed which have no periosteal 
attachments. In the majority of instances it is better to 
approximate the fragments with silver wire, disturbing the 
periosteum as little as possible. If the approximated bone 
cannot be covered with periosteum nor healthy skin, it 
should be covered with a muscle-flap. Every effort should 
be made to cover the bone at the seat of the fracture. If 
possible, the skin opening should be closed. The indica- 
tions for drainage — which is best accomplished by rubber 
tissue, never a drainage-tube — are excessive hemorrhage 
from the bone and laceration or contusion of the soft parts 
which threatens their circulation. If this is excessive, the 
skin wound should be left wide open. In such instances 
frequent dressings are indicated to prevent or inhibit sec- 
ondary infection. It is remarkable what excellent results 
can be obtained in the most grave cases of compound frac- 
ture by early and proper operative interference, proper 
drainage, and the most careful after-treatment. — Ed.] 

Varieties of Fracture 

According to the degree of separation of the fragments, 
fractures are divided into complete and incomplete. The 
latter class includes fissures, traversing the bone without 
producing any alteration in its outward form ; infractions 
( " greenstick " fractures), which occur most commonly in 
children, particularly in the bow-legs of rachitic children, 
although occasionally also in the long bones of adults ; and 
depressed fractures, which occur chiefly in flat bones. 

In a complete fracture the line may assume various 
forms ; hence we distinguish transverse, oblique, longitud- 



22 FRACTURES AND DISLOCATIONS. 

PLATE 1. 

Bending Fractures (Greenstick Fractures). — Fig. 1 a and b. 
— Tibia and fibula of the left lower extremity. From a boy, fourteen 
years old, who was caught between the cogwheels of a threshing- 
machine. The outer surface of the two bones is shown; the epiphy- 
seal lines are still visible. The fracture of the fibula appears about 2 
inches higher than that of the tibia. Both bones are bent at the seat 
of fracture, forming on the outer surface a projecting, and on the inner 
surface a receding, angle. The bending first produced a solution of 
continuity on the convex surface, the fracture being completed by the 
formation of the characteristic wedge, which, however, has not com- 
pletely separated, and is still held in place by a bridge of bone, at the 
lower border in the case of the tibia, at the upper border in the case of 
the fibula. (From the author's collection.) 

Fig. 2 a and b. — Tibia and fibula from the skeleton of an adult 
after a fracture had been produced artificially with the aid of Kizzoli's 
osteoclast. It is seen at a glance that the fracture was produced by 
bending the bone. The tibia shows an excellent sample of oblique 
fracture. (From the author's collection.) 

inal, and spiral fractures. If the bone is broken into a 
number of small fragments, which may or may not be 
held together by periosteum, we speak of a comminuted or 
splintered fracture. There may be multiple fracture of the 
same bone, as fracture through the upper, lower, and 
intermediate portions ; and simidtaneous fractures of sev- 
eral bones, as, for example, fracture of both bones of the 
forearm or leg, or of various bones situated at some dis- 
tance from one another. 

It is not without importance to determine whether a 
fracture is direct or indirect. These terms are used to 
indicate the seat of fracture in relation to the point of 
impact of the breaking force. If the seat of fracture cor- 
responds with that of the injury, — as, for example, frac- 
ture of the ulna sustained in warding off a blow (" parry- 
ing fracture "), — the fracture is said to be direct. But 
when a child falls on its outstretched hand and sustains a 
fracture of the clavicle or of the lower end of the humerus, 



Tab. I. 




«^,M>-_ 



%-* « Tiff J b 




Fiff.Sa R&2 b 



lAlh.Ansl F.Reichhold, Miiiuhen. 



GENERAL CONSIDERATIONS. 23 

it is called an indirect fracture. Since the effects of the 
insult, consisting in contusion and subcutaneous hemor- 
rhage, occupy the seat of the fracture itself in direct 
fractures, the latter are generally considered more serious 
than indirect fractures. 

Another important point is the incidence of certain 
forms of fracture according to age. That the greatest 
number of fractures occur among adults is easily under- 
stood, since this class is most engaged in heavy labor, and 
accordingly exposed to the dangers and accidents incident 
thereto. To obtain a correct idea of the significance of 
statistics it is necessary, however, to remember the relation 
of the total number of inhabitants to the different periods 
of life. Keeping this in mind, it is found that fractures 
are most frequent between the ages of thirty and forty 
(15.4 ^i) ; fractures are more common in old persons than 
in children, the latter up to the age of ten representing 
the minimum of incidence. The frequency of fractures 
in old age is partly explained by the increased brittleness 
of the bones due to senile atrophy of the bony tissue (dim- 
inution of organic constituents in the bones). In youth 
the presence of a cartilaginous joint between diaphysis and 
epiphysis plays an important role in the etiology ; instead 
of actual fracture of the long bones, epiphyseal separations 
are more likely to take place, similar to those which occur 
spontaneously in inflammatory processes, such as syphilis 
and, especially, acute osteomyelitis. 

The degree of force necessary to produce a fracture 
varies greatly. As has been said, a comparatively slight 
force suffices in the case of children (epiphyseal separation) 
and old persons (senile atrophy). In a healthy adult the 
resistance of individual bones varies ; thus, the following 
widely differing results were obtained by actual tests : 

Female clavicle 126 kg. 

Female humerus . 600 " 

Male radius 334 " 

Neck of femur in a man 815 " 

Tibia ........... 450-650 " 



24 



FRACTURES AND DISLOCATIONS. 



Iii rare instances fractures have occurred, without any 
accident, while the individual was engaged in ordinary 
work, such as climbing a ladder with a load on his back. 
These are the so-called occupation or work fractures. 1 

Our knowledge of the mechanism of fractures is obtained 
from a study of specimens that happen to present a frac- 
ture and of fractures produced artificially on the cadaver. 
The results obtained in these two different ways are found 
to agree. Most forms of fracture can be produced with very 
little trouble ; and a little experience and careful observa- 






Fig. 1. — Various forms of typical bending or greenstick fractures : 
a, Oblique fracture ; b, transverse fracture with fissures ; c, oblique 
fracture with separation of a wedge-shaped piece. 



tion will enable one in most cases to determine, by an ex- 
amination of the specimen, the mechanism of the fracture — 
i. e. y the way in which it occurred. Such knowledge may 
be useful in medicolegal cases. 

A bending (or greenstick) fracture (Plate 1) is pro- 
duced by bending the bone beyond the limits of its elas- 
ticity. The so-called relative or bending resistance of the 
bone is overcome by a force acting from without in a 

1 Golebiewski, ' * Atlas and Epitome of Diseases Caused by Acci- 
dents," W. B. Saunders & Co., 1900. 



GENERAL CONSIDERATIONS. 25 

direction perpendicular to the long axis of the bone. 
When a stick is bent and finally broken across the knee, 
the convex side is the first to yield, and precisely the 
same thing occurs in a long bone that is broken in the 



Fig. 2. — Characteristic bending or greenstick fracture of the fore- 
arm, especially the radius. Skiagraph. In both bones the fracture 
is incomplete. The boy had been injured by a machinery belt. In 
reducing the fracture it was rendered complete, but without any addi- 
tional displacement. Good recovery. 

same way. In actual practice such a fracture may be pro- 
duced in various ways ; as, for example, by an overload 
applied to the unsupported middle portion of the bone, 
or by bending the bone while one extremity is fixed. 
This variety of fracture results when the osteoclast is used 



26 FRACTURES AND DISLOCATIONS. 

PLATE 2. 

Torsion =fractures.— Fig. 1 a and ft.— Torsion fracture of the 
upper half of the shaft of the femur in a woman eighty years of age. 
The fracture was produced by rotation of the body while the foot re- 
mained fixed. The illustration shows the anterior aspect of the (left) 
thigh bone with a beautiful spiral line of fracture. Figure 1 b shows 
the two fragments separately (opened like valves, as it were). The 
spiral form, the acutely oblique fracture, and the longitudinal portion 
of the line of fracture are readily recognized. (Author's observation.) 

Fig. 2 a and b. — Artificial fracture of the femur by torsion. The 
illustration shows the spiral line passing upward and to the right. 
In figure 2 b the rhomboidal fragment is shown, turned back like the 
lid of a box ; it was produced by two longitudinal lines of fracture 
running into the spiral line. (From author's collection. ) 



or when one of the weaker bones is broken over the edge of a 
table. A bending fracture results also when the rigidity of 
a long bone is overtaxed ; the bone at the same time sustains 
a bending and a compressing force in its longitudinal direc- 
tion and fracture results at the weakest point, where the 
bending is greatest, as soon as the limit of perfect elasticity 
is overstepped. A practical illustration of this mechan- 
ism may be observed when, after gunshot-fracture or frac- 
ture by torsion of the tibia, the individual attempts to get 
up and the fibula is snapped in two by the weight of the 
body (see Plate 65, Fig. 1). 

It is important for medicolegal purposes to remember 
that a greenstick fracture has a very characteristic appear- 
ance and is easily recognized in the anatomic specimen. 
The convex side presents a fissure or crack which is 
usually converted into a complete fracture by the sudden 
separation of a wedge of bone. The base of this wedge, 
which may be partially or completely separated, or only 
outlined by fissures in the bone, always corresponds to the 
concave side of the broken bone. It is evident that the 
bending of the bone may result in a fissure, an infraction 
(incomplete fracture), or a complete fracture, accompanied 



Tab. 2. 




Iig.1* 






Ycf.JZcr 



■Fig.Sb 



Lith. Arist E Reich) w Id, Minrtien . 



GENERAL CONSIDERATIONS. 



27 



sometimes by separation of a fragment. Depending on 
the shape, size, and direction of the wedge of bone, the 
fracture will be either transverse or oblique. 




Fig. 3. — Typical torsion-fracture of the tibia. Skiagraph. A 
laborer twenty-seven years of age fell on the street and sustained 
a fracture of the leg. The clinical diagnosis of supramalleolar torsion- 
fracture of the tibia was confirmed by the Kontgen-ray picture. 
Even under anesthesia it was found impossible to replace the frag- 
ments ; the fracture was accordingly laid open and the fragments 
adjusted and fixed with silver wire. The patient made a perfect 
recovery. 



28 FRACTURES AND DISLOCATIONS. 

PLATE 3. 

Fractures Produced by Compression, Tearing, and Crush- 
ing. — Fig. 1 a and b. — Impacted fracture of the upper end of the 
tibia, which is wedged in between the remaining fragments. This is 
the famous specimen in the collection of the Pathologic Institute at 
Giessen. Figure 1 a presents an anterior view of the bone, figure 1 
b a longitudinal (coronal) section. One illustration supplements the 
other, and together they show the effect of force applied at the upper 
border of the tibia, driving the bone in between the condyles of the 
femur. The cliaphysis of the tibia has been wedged into its epiphyseal 
fragments, which have spread out in all directions. 

Fig. 2. — Fracture by muscular action of the distal extremity of the 
bones of the forearm. The two styloid processes are broken off, the 
lines of fracture being serrated. The fracture occurred in a machine- 
accident and was produced by a sudden pull transmitted through the 
lateral ligaments. The fracture of the ulnar styloid process is incom- 
plete. That of the radius complete. 

Fig. 3. — Comminuted fracture of the bones of the forearm at their 
distal extremities by a machine-accident. Male, aged fifty, while tend- 
ing a steam-engine, slipped and caught his arm in the drum. Imme- 
diate amputation was performed, as the soft parts were badly contused. 
There was also a fracture of the humerus. Eecovery from the opera- 
tion with good union of the humeral fracture. (Author's collection.) 



Finally, we may distinguish one more variety of frac- 
ture by bending or crushing produced by direct lateral 
pressure against the extremity of a bone in fixation, with- 
out actual bending at the seat of fracture ; as, for ex- 
ample, fracture of the fibula by the pressure of the astrag- 
alus in a typical fracture of the ankle. In this accident 
the pushing or gliding resistance of the bone is overcome. 

Fracture by torsion (Plate 2) is produced by a rotatory 
force overcoming the rotatory resistance or resistance to tor- 
sion of a long bone. Rotation of the bone eventuating in 
fracture is possible whenever one segment of the bone is 
fixed while the remaining segments are rotated. Thus, a 
torsion-fracture may be produced either by rotating the 
distal portion of the limb while the body remains fixed, 



Tab.3. 




Fig.l 










/<>' 
Wl 



I 



ify.16 



-X 




^ 







GENERAL CONSIDERATIONS. 29 

or, inversely, by rotating the body while the extremity is 
fixed. The latter is the more frequent accident ; thus 
fracture of the femur by rotation of the body during a 
fall, the foot and leg remaining fixed, not infrequently 
occurs. The former mechanism is imitated when by an 
artificial torsion a fracture is produced on the cadaver ; it 
must be, however, supplemented by a sharp blow with a 
hammer on the desired seat of fracture. The line of frac- 
ture thus produced is usually distinctly spiral. The spiral 
line in this so-called fracture by torsion, or spiral frac- 
ture, is, as a rule, readily recognized. If the bone has 
been rotated to the right, — that is to say, in the same 
direction as an ordinary right screw when it is being 
screwed home, — the resulting line of fracture will repre- 
sent a spiral wound to the right. As, in addition to the 
spiral line, a double longitudinal fracture is produced, 
there is always a partially or completely separated rhom- 
boidal fragment which is characteristic of torsion- fractures. 
The short sides of this rhomboidal fragment are formed 
by sections of the spiral line. Thus we have acute-angled 
oblique fractures or longitudinal fractures, and, occasion- 
ally, oblique fractures with longitudinal fissures. Fracture 
by torsion is by no means a rare occurrence (humerus, 
femur, tibia). Although it is probably always due to in- 
direct violence, the prognosis is unfavorable because of 
the jagged fragments, which tend to become displaced and 
perforate the skin, rendering the fracture compound, and 
because of the great extravasation of blood. 

[The subject of torsion-fractures has recently been thor- 
oughly considered by Zuppinger. 1 — Ed.] 

Compression-fractures (Plate 3), or contusion- 
fractures, are produced by external violence causing a 
sudden compression of the bone. The compressing force is 
usually transmitted by a contiguous bone of greater density. 
Compression of a long bone in the direction of its long 

1 Beitrage zur klin. Chirurgie, 1900, vol. xxvn, p. 735, with eight 
X-ray photographs. 



30 FRACTURES AND DISLOCATIONS. 

PLATE 4. 

Gunshot=fractures. — Effects of the German army rifle, model 88, 
ivith a projectile of 7.9 mm. diameter, propelled by a full charge of powder 
at actual distances. 

Fig. 1. — Gunshot wound of the shaft of the femur. Distance 600 
meters. Wound of entrance on the anterior aspect of the bone, sur- 
rounded by radiating lines of fracture forming a number of splinters 
of various sizes. *The splinters have been replaced like the parts of a 
mosaic, and the continuity of the macerated bone restored by insert- 
ing a wooden rod into the medullary cavity. (From author's collec- 
tion. ) 

Fig. 2. — Gunshot wound of the shaft of the tibia. Distance 50 
meters. The illustration shows the wound of entrance on the anterior 
surface of the tibia. The splinters have been restored to their original 
positions so that the characteristic stellate appearance of the fracture 
with the loss of substance in the center is shown. 

Fig. 3 a and b. — Perforating (" button-hole ") gunshot-fracture of 
the upper end of the humerus. Distance 1500 meters. In the recent- 
state the specimen presented a clean perforation with smooth edges 
through the soft parts, periosteum, and bone. The projectile, which 
is shown in figure 3 b entered the anterior surface of the arm and, 
after producing the perforation shown in the illustration, lodged be- 
neath the skin of the posterior surface. The macerated specimen 
shows a fissured fracture beginning at the point of entrance and run- 
ning upward and outward through the tuberosities, almost completely 
encircling the anatomic neck. The wound of exit on the posterior 
surface of the humerus is somewhat smaller than the wound of en- 
trance, and presents a circular outline. (From author's collection. ) 

axis by a sprain (or contusion) results in a characteristic 
partial fracture — infraction — of the spongy tissue in the 
extremity of the bone, or in impaction of the fragments, — 
impacted fracture , — the narrower and more compact diaphy- 
seal fragment being driven like a wedge into the more 
voluminous and spongy epiphyseal extremity ; or, rarely, 
it may result in complete shattering of the bone. The 
following are examples of compression-fractures : Fracture 
of the upper end of the humerus (Plate 33, Fig. 3) ; 
fracture of the neck of the femur by a fall on the trochan- 



Tab. ■ 




M 




Eig.l. 




Fif/.J <t 




Fig.3 b 



Ficf.,2. 
I.ith . Arvst E Reichhold, Munrhen . 



GENERAL CONSIDERATIONS. 31 

ter (Plate 54) ; fracture with contusion of the calcaneum, 
resulting from a fall on the feet ; fracture of the upper 
end of the tibia (Plate 63, Fig. 3, a and b ; Plate 3, Fig. 
1, a and b). This class also includes cases in which a 
small plate of bone becomes separated from the margin of 
a joint (true "sprain-fracture"). 

In the production of an impacted fracture the so-called 
retroacting resistance or resistance to pressure of the bone 
must be overcome. 

Fracture by muscular action is produced by the 
sudden pull of muscles or ligaments in forcible movements 
of joints (distortion), and, rarely, by external violence 
(machinery belts). Typical examples of this class are 
found in fracture of the patella, of the olecranon, of the 
ankle, of the lower radial epiphysis, etc. In this variety 
the so-called absolute resistance or resistance to traction of 
the bone must be overcome. 

Comminuted fractures (Plate 3, Fig. 3) are produced 
in various ways by powerful external violence (machine 
injuries). The bone may be broken into a number of 
pieces or completely pulverized. 

Gunshot-fracture (Plate 4) is produced by gunshot 
wound of a bone. A full charge of shot discharged at 
short range may produce an extensive comminuted frac- 
ture such as a rifle-ball inflicts. A gunshot wound by a 
modern weapon, such as the German army rifle, model 88, 
discharged at a distance of 800 meters or less usually re- 
sults in extensive shattering of the shaft of a long bone. 
This powerful effect was also observed in 1870 in the case 
of Chassepot rifles when discharged at very short range, 
and the explanation then given was that the French used 
explosive bullets. This assumption was later found to be 
erroneous, nor is the theory of hydrostatic pressure within 
the bone (marrow) tenable. At the present day the phe- 
nomenon is explained by the sudden and violent displace- 
ment of the molecules of the bone, the effect of which 
extends some distance beyond the point of impact. 



32 FRACTURES AND DISLOCATIONS. 

If the range exceeds 700 or 800 meters, the resultant 
wound may be a perforation even in the diaphysis of 
a bone, and the wound tends to heal kindly. In the 
spongy portions of the bone (epiphysis) perforations are 
observed at distances of 600 meters and over. 



Symptoms of a Recent Fracture 

In the examination of a patient suffering from an injury 
it is advisable to gain a general impression of his condi- 
tion before examining by manipulation the painful part. 
The character of the functional disturbance — the way in 
which a patient supports the injured arm, for instance — 
often points to the correct diagnosis. A complete examina- 
tion is particularly important if the patient is unconscious, 
since he cannot call attention to the injured part and shows 
no sign of pain; in such a case the entire body must be gone 
over and every swelling and ecchymosis conscientiously 
examined. 

The characteristic features of a fracture depend on the 
solution of continuity in the bone. This solution of conti- 
nuity and its mechanical consequences constitute the most 
important symptoms of fracture. 

1. Abnormal mobility is the most important symp- 
tom. It is more or less pronounced in most cases of frac- 
ture and can usually be demonstrated. It is absent in 
incomplete fractures — fissured fractures — and in impacted 
fractures. In the latter the dense narrow fragment of the 
shaft is driven into the softer, spongy portion of the 
epiphysis and becomes mechanically fixed, so that the two 
fragments practically form a single bone. While this 
variety is most frequent in fracture of the neck of the 
femur, it also occurs in fractures of the articular extremi- 
ties of other long bones. In some cases, such as fracture 
of short bones like the ribs, etc., it is often impossible to 
demonstrate abnormal mobility. 

2. Crepitus or crepitation is the grating sensation pro- 



GENERAL CONSIDERATIONS. 33 

duced by rubbing together the broken surfaces, and may 
be elicited when there is displacement of the fragments. 
It is usually detected by the sense of touch, but may also 
be heard. Abnormal mobility is a necessary condition for 
the production of crepitus ; if it is absent and the ends of the 
fragments are not displaced, crepitus cannot be produced. 
Hence crepitus cannot be elicited in fissured fractures and 
in incomplete and impacted fractures. In some cases in 
which no abnormal mobility can be demonstrated, crepi- 
tation, or at least a gentle rubbing noise, may sometimes be 
elicited by appropriate manipulation, and thus determine 
the diagnosis of fracture. 

But a typical abnormal mobility may in some cases be 
quite clearly recognized and yet no crepitus elicited. 
Hence the second condition for the production of crepitus 
is that the ends of the fragments be in contact. Crepitus 
is therefore absent when the displacement of the fragments 
is such that the ends are not in contact (dislocatio ad Ion- 
gitudinem), either because they are separated (diastasis), 
as, for instance, in fracture of the patella, or because there 
is marked longitudinal displacement with great shortening 
of the entire bone (overriding). 

Crepitus is also absent when the ends of the fragments 
are prevented from coming into contact with one another 
by the presence of soft parts ; in other words, when there 
is an interposition of soft parts (usually parts of fascise or 
muscles). This occurs when there is great displacement 
of the roughened ends of the fragments so that they pene- 
trate the surrounding soft parts, from which they are not 
entirely freed when the fracture is reduced. The inter- 
vening tissue acts like a cushion and prevents contact 
between the ends of the fragments. [In fractures of the 
neck of the femur no attempt should be made to elicit 
crepitus for diagnosis. Such an attempt would break up 
an impaction, if present, and an impaction is the best thing 
that can happen in a fracture of the neck of the femur. 
Here the diagnosis should and can be made by the inspec- 
3 



34 FRACTURES AND DISLOCATIONS. 

PLATE 5. 
Displacement of Fragments.— Figures 1 and 2 present different 
views of the same specimen, being that of a fracture of the femur. It 
shows all the different forms of displacement. 

tion of the deformity and by measurements. Unnecessary 
manipulation is frequently employed in the diagnosis of 
injuries about the hip-joint. — Ed.] 

3. Deformity. — This is another very important symp- 
tom which can usually be both seen and felt. It is absent 
only in fissured fractures and in those rare complete frac- 
tures in which there is no displacement of the fragments. 
The finding of this symptom clinches the diagnosis. In 
certain cases fracture of some hidden portion of the bone 
can only be inferred by finding displacement of certain 
accessible bony points, as, for instance, in fracture of the 
neck of the femur. Careful inspection and palpation (dig- 
ital examination) of the injured part should never be neg- 
lected, the findings being, if possible, controlled by com- 
parison with symmetric parts of the sound side. Shortening 
of the fractured bone is rarely absent. 

The deformity is due to the displacement of the frag- 
ments. It has long been customary to describe various 
forms of displacement (compare Plate 5) — namely (see 
Fig. 4) : 

(a) Lateral displacement (dislocatio ad latus) ; (6) angular 
displacement of the fragments {dislocatio ad axin) ; (c and 
d) longitudinal displacement (dislocatio ad longitudinem). 
This variety is further divided into separation of the frag- 
ments (diastasis ; dislocatio ad longitudinem cum distrac- 
tione), where the fragments are drawn apart, as in fracture 
of the olecranon and patella, and into so-called " overrid- 
ing " of the fragments (dislocatio ad longitudinem cum con- 
traction), in which the fragments are displaced laterally 
and the ends by one another, so that the entire bone be- 
comes shortened; this frequently occurs in fracture of the 
long bones, (d and e) Rotatory displacement of one or both 



Tab. 5. 



i 



/ %■ 




Uq.l. 



Eig.2, 



Lfflh. Arist E Reich} u\ « 



GENERAL CONSIDERATIONS. 



35 



fragments about the long axis of the bone (dislocatio ad 
periphe/'iam). This is not infrequently present in a slight 
degree. The deformity occurs in a pronounced form in 
fracture of the neck of the femur and in fractures of the 
shaft of the femur and radius, the distal fragment under- 
Q-o'mGr rotation when the rest of the limb is in its normal 
position. 

Causes of the Deformity. — In very many cases it is the con- 
tinued action of the trauma after the fracture has taken place 
that produces the displacement of one or both fragments. 
In another class of cases the unopposed pull of the muscles, 
acting on one or both fragments, produces displacements ; 




f 



41* 



y 



Fig. 4. — Schematic illustration of various forms of displacement : 
a, Lateral ; b, angular ; c, overriding ; cZ, separation ; e, rotatory. 



for example, the action of the iliopsoas muscle on the upper 
fragment in fracture of the femur, causing flexion of the 
thigh ; the action of the masseter, temporal, digastric, and 
other muscles in fracture of the lower jaw ; action of the 
quadriceps in fracture of the patella ; of the triceps in 
fracture of the olecranon. Finally, we have as a third 
cause of the deformity, the effect of gravity on the injured 
part. Thus, for instance, in fracture of the middle third 
of the clavicle the outer fragment is displaced downward 
by the weight of the arm. 

4. Extravasation of blood and other phenomena in 
the external soft parts are, as a rule, more pronounced in 
direct fractures. In these the bone is injured at the point 



36 FRACTURES AND DISLOCATIONS. 

where the crushing force is applied. Extravasation into 
the tissues is never absent ; in articular fractures it takes 
the form of a hemarthrosis. Excoriations are not infre- 
quently present, more rarely subcutaneous perforation of 
the skin from within by a sharp fragment, as, for in- 
stance, in fracture of the upper end of the humerus (see 
Fig. 55). If the extravasation is profuse, it may seriously 
interfere with digital examination of the fracture. [Local- 
ized ecchymosis, especially if the trauma has been an in- 
direct one, is a very important point in the diagnosis of an 
obscure fracture. — Ed.] 

5. Pain as a symptom of ordinary fracture loses much 
of its value from the fact that it is a purely subjective 
phenomenon. The pain of a contusion is said to be differ- 
entiated from that of a fracture by the fact that in the 
latter condition careful manipulation of the injured limb 
brings out an intense pain localized to a definite point (like 
pain on pressure), while in a contusion the pain is felt uni- 
formly over a larger extent of the injured bone. Pain 
may be a very valuable symptom in indirect fractures ; 
that is, when the crushing force was applied at some point 
distant from the seat of injury. Occasionally, particularly 
in fracture of the bony prominences situated on the artic- 
ular extremities of bones and in incomplete fracture, the 
pain produced by certain movements and during the action 
of certain muscles that have their origin or insertion at 
these points is a symptom of some value (pain on motion). 
In doubtful cases of suspected fissured, incomplete, or im- 
pacted fractures, the attempt to produce pain at the sus- 
pected point by sudden compression of the bone or limb 
in its long axis, without directly touching the injured spot, 
is often of material aid in the diagnosis. 

[Pain and tenderness at the site of the supposed fracture 
are important points in diagnosis only when the trauma 
has been an indirect one. In direct trauma the pain and 
tenderness from a contusion of the periosteum cannot 
always be differentiated from that of a fracture. — Ed.] 



GENERAL CONSIDERATIONS. 37 

6. Disturbance of Function. — This symptom obvi- 
ously depends to a large extent on the individual's dis- 
position. There are on record undoubted cases of patients 
who have walked after a recent impacted fracture of the 
neck of the femur or after fracture of the fibula alone, and 
of others who used the arm after fracture of the ulna or 
continued standing at their work after a compression-frac- 
ture of the vertebral column. 

Finally, it must not be forgotten that the history, — that 
is, information in regard to the manner in which the in- 
jury occurred, and its subsequent course, — the manner in 
which the individual was struck or the way in which he 
fell, are all important points in the -diagnosis. 

The Examination of a Fracture 

The first requisites are gentleness and dispatch. Inspec- 
tion will often give all the necessary information, leaving 
only certain special questions to be decided by manual ex- 
amination of the seat of fracture. In examining a frac- 
ture the surgeon must always aim at obtaining an accurate 
knowledge of the nature of the fracture and of the shape 
and position of the fragments. To do this it is often 
necessary to resort to anesthesia, especially in so-called 
joint fractures. One who in doubtful cases makes it a 
practice to examine under anesthesia (chloroform, ether, 
or bromid of ethyl) with all due precautions will never 
regret it. The accurate and correct idea of the state 
of affairs which is thus obtained will be of the greatest 
value in the course of the treatment, and, besides, the 
fragments can at once be replaced while the patient is still 
under the influence of the anesthetic. While it is perfectly 
true that an experienced surgeon can usually manage to 
arrive at a diagnosis and reduce the fracture without re- 
sorting to anesthesia, I nevertheless believe I am justified 
in recommending to physicians in general practice a more 
frequent use of narcosis as the best means of perfecting 



38 FRACTURES AND DISLOCATIONS. 

themselves in this important and often very difficult sub- 
ject. The examination under anesthesia need not neces- 
sarily be made while the fracture is recent ; barring ex- 
ceptional cases, there is no harm done by putting it off, 
providing it is done within a week. 

The difficulty and responsibility of the first examination 
are especially great when the subject is unconscious. The 
surgeon must not forget that the finding of one fracture 
does not necessarily exclude the presence of others, — i. e., 
multiple injuries and dislocations, — and that a careful 
examination of all the bones and joints is the only sure 
way to avoid fatal mistakes. 

A very important procedure in the examination of a 
fracture is mensuration ; as there is nearly always shorten- 
ing of the broken bones, the finding of a difference in the 
length of the two limbs is very significant. One should not 
at once proceed to use the tape-measure ; on the contrary, 
the proper thing to do is to place the injured limb in 
symmetric position with respect to the sound side, and 
subject it to an accurate comparison by inspection from a 
certain distance. One who has diligently trained himself 
will often be better able to detect slight differences by the 
eye than by means of the tape-measure, though one should 
also practise actual mensuration. 

Ultimate Result in Fracture. — The examination of cases 
of long standing such as frequently present themselves 
nowadays requires the utmost care in order to decide the de- 
gree of disability. In the great majority of such cases de- 
formity is found to be the cause of the permanent disability. 
In these, as in all other cases, the objective changes and sub- 
jective symptoms should be susceptible of being brought 
into a certain harmony. The surgeon must be on the 
lookout for any alteration in form and evidence of dis- 
placement at the seat of fracture, the presence of edema, 
injury of a neighboring nerve-trunk (radial nerve, exter- 
nal popliteal nerve), atrophy of the muscles, etc. It re- 
quires no small measure of experience and shrewdness to 



GENERAL CONSIDERATIONS. 39 

convict a man of exaggeration or malingering even after 
a thorough examination. If positive evidences of an 
abnormal condition are found, it must be remembered that 
the alterations in the external form frequently do not cor- 
respond with the degree and extent of destruction of the 
bone, — as, for instance, in fracture of the metatarsus, — 
and that it would be unjust to the patient to judge of his 
condition merely by the external objective changes. 

[The estimation of the disability in old fractures is 
frequently a difficult one. We may speak of a perfect 
anatomic result and a perfect functional result. With 
rare exceptions a perfect anatomic result is always associ- 
ated with a perfect functional result. By a perfect 
anatomic result we mean that the fracture has healed 
without deformity and without shortening. Nevertheless 
in some instances the patients suffer pain and discomfort, 
and the function of the limb is not perfectly restored. 
This is usually due to more or less ankylosis of a neigh- 
boring joint caused either by some injury to the joint at 
the time of the fracture, or a fracture into the joint, or 
improper and prolonged fixation of the limb. On the 
other hand, the functional disability may be due to the 
involvement of a nerve in the scar tissue. 

An imperfect anatomic result is by no means always 
associated with impaired function, and it is this fact that 
complicates the estimation of the disability of an individual 
case. Nor is there a definite relation between the defec- 
tive anatomic result and the use of the limb. This fact we 
frequently observe in fractures of the neck of the femur, 
Colles' fracture, and Pott's fracture. In the three fractures 
mentioned the good function of the limb, notwithstanding 
a very bad anatomic result, is frequently remarkable. 
We must also remember that there is not uncommonly a 
marked neurasthenic condition associated with fractures 
which may or may not be good anatomic results. — Ed.] 

Examination by Means of Rontgen Rays. — The 
use of the Rontgen rays in the examination of fractures 



40 FRACTURES AND DISLOCATIONS. 

has justly become a universal practice. No surgical hos- 
pital is complete without a Rontgen-ray apparatus. Many 
practising physicians, even in the country, resort to its 
use, and many patients resort to the skiagraph behind the 
doctor's back to obtain their desired information. The 
practical value of the Rontgen rays in the examina- 
tion of fractures is no doubt sometimes overestimated, but 
the method unquestionably possesses very great value — 
a much greater value than many skeptics are willing to 
accord it. One thing, however, is important. The exam- 
ination with the Rontgen rays is a method that requires 
for its proper application special study and training, if 
correct and trustworthy results are to be obtained. There 
are, of course, many text-books on this subject and space 
forbids a full treatment here. I will only bring out a few 
practical points that have occurred to me during a some- 
what extended use of the method. 

In examining a fracture of a long bone by means of the 
Rontgen rays two skiagraphs should always be made : an 
anterior (or posterior) view, and a lateral view. This is 
absolutely necessary to obtain a clear idea of the displace- 
ment at the seat of fracture, and it may even be necessary 
in certain cases to prove the very existence of a fracture 
(compare Plate 6). 

For purposes of comparison the Rontgen-ray examina- 
tion should not be confined to the fractured bone, but a 
skiagraph should also be made of the corresponding bone 
on the sound side. It is, of course, indispensable for the 
correctness of the comparison that the two skiagraphs be 
taken under exactly similar conditions. Hence the Ront- 
gen tube and the limbs to be photographed must be sym- 
metrically arranged. 

In exceptional cases the deformity of a fracture may 
appear greater and more marked in the skiagraph than it 
is in reality. 

[The exaggeration of the deformity in the skiagraph 
should be constantly borne in mind. I have observed this 



GENERAL CONSIDERATIONS. 41 

quite frequently in the X-ray negative taken of a Colles' 
fracture after reduction. A careful external examination 
demonstrated apparently a perfect anatomic result, yet the 
X-ray negative showed a considerable separation between 
the fragments. Yet in these cases the ultimate result was 
apparently a perfect one. 

The length of exposure is important, since certain con- 
ditions, such as beginning callus-formation and fissured 
fractures, are brought out by a short exposure, but do not 
appear in the photographic plate if the time of exposure is 
too long. 

A knowledge of the normal shape of the bones, both in 
nature and in the Rontgen-ray image, is indispensable in 
interpreting the skiagraph of a fracture ; otherwise, the 
picture of an epiphysis or of accidental indentations or 
dark lines might be mistaken for a fissure or the line of a 
fracture. For this reason a thorough knowledge of the 
articular ends of bones as seen in the Rontgen image is 
peculiarly important, and it demands a great deal of study. 
It must not be forgotten that the Rontgen-ray picture is 
nothing but a shadow picture which by means of light and 
heavy shading reproduces the density of tissues, especially 
of bone. 

[A special knowledge of the time of the ossification of 
the epiphyses is required to properly interpret the X-ray 
fractures near the epiphysis. This subject has recently 
been fully discussed by Wolff. 1 — Ed.] 

The usefulness of the Rontgen-ray picture is not confined 
to the recognition of a fracture and of the individual condi- 
tions of the case ; it is also valuable during the treatment, 
enabling the surgeon to determine whether reduction has 
been successful and the fragments are in good position. 

1 Dent. Zeitschr. f. Chir., 1900, Bd. Liv, p. 287, reviewed in Pro- 
gressive Medicine, December, 1900, p. 135. 



42 FRACTURES AND DISLOCATIONS. 

PLATE 6. 
Fracture of the Fibula as shown by a Skiagraph. — Fig. 
1. — Anterior view. Fig. 2. — Lateral view. The patient, a man 
forty -four years of age, fell on the ice and with difficulty managed to 
get home. Pain on pressure was elicited in the fibula, but there was 
no deformity. The anterior view does not show the fracture, which 
is distinctly seen in the picture taken from the side. 



The Diagnosis of Fracture 

The diagnosis of a fracture ought not to be difficult in 
most cases, if all that has been said in regard to the 
symptoms and the examination is carefully borne in mind. 
If, however, displacement is altogether absent or barely 
perceptible, owing to impaction of the fragments or be- 
cause one has to deal with a simple infraction or a fissured 
fracture, it is sometimes impossible to make a positive 
diagnosis. The clinical appearances in contusion or dis- 
tortion are frequently indistinguishable from those ob- 
served in fissure or infraction, and the diagnosis of a 
fracture may remain in doubt until the formation of callus 
and pronounced disturbance of function clear up the situ- 
ation. 

The diagnosis includes, besides the determination of the 
presence of a fracture, the recognition of its details : dis- 
placement of fragments, the presence of splinters and of 
soft parts between the ends of the bones, etc. 

Special methods of diagnosis, such as acupuncture and 
percussion (osteophony), are of little practical value and 
have failed to become popular. On the other hand, the 
use of the Hontgen rays is, as has been stated, a diagnostic 
method of the utmost importance. It is by means of this 
method that the knowledge of fractures and dislocations 
has been materially enriched in a comparatively short 
space of time by the discovery of hitherto unknown facts 
and by the recognition of errors that had obtained up to 
the time of its advent. It is to be distinctly remembered, 



GENERAL CONSIDERATIONS. 43 

however, that careful examination usually suffices to make 
the diagnosis and determine the treatment of a fracture, 
and should always precede the employment of the Ront- 
gen-ray apparatus. The latter, however, in most cases 
supplies us with more detailed information in regard 
to the displacement of fragments which is of great value 
at the very beginning of treatment. 

[One should never hesitate, if in doubt with regard to 
diagnosis of a fracture, to treat the injury as a fracture, 
and, if there is a deformity which cannot be reduced under 
anesthesia, to operate. This is especially true in partial 
epiphyseal separation. I believe many of the recorded 
bad results could have been prevented by operation, which 
allows not only a better recognition of the injury, but a 
more perfect reduction of the deformity. — Ed.] 



Clinical Course and Repair of Fractures 

The production of a fracture is followed by swelling 
of the surrounding soft parts, due in part to the out- 
pouring of blood, in part to infiltration of the tis- 
sues. The swelling is proportional to the severity of 
the injury, the amount of hemorrhage, and the length 
of time that intervenes between the injury and the proper 
replacement of the fragments. These conditions do not, 
of course, fail to affect the organism as a whole. In addi- 
tion to blood, the seat of fracture contains lacerated bone- 
marrow and other tissue elements. This explains why a 
recent subcutaneous fracture in a healthy individual is 
frequently followed by the occurrence of fever. The ex- 
planation of the phenomenon may be found in the resorp- 
tion of minute decomposing tissue elements at the seat of 
fracture, but it is probably more correct to assume that 
the rise in temperature is produced by the action of the 
blood ferment which is absorbed from the extravasated 
blood. That resorption of blood ferment may produce 
fever has been proved experimentally by Angerer. 



44 FRACTURES AND DISLOCATIONS. 

[So far observations have demonstrated that there is no 
leukocytosis associated with the fever frequently present in 
simple fractures. — Ed.] 

The laceration of the bone-marrow may permit the 
escape into the circulation of larger or smaller masses of 
fat (for Fat Embolism see page 50), which is in part 
excreted by the kidneys ; accordingly, fat and sometimes 
albumin and casts may be found in the urine after frac- 
ture. 

[Death from fat embolism following fracture is very 
rare. It has been more frequently recorded after fracture 
of the shaft of the femur. — Ed.] 

The early and softer tumefaction about the seat of frac- 
ture is due partly to the extravasation of blood and partly to 
a form of inflammatory exudate (edema), and may persist 
for several days. Under proper treatment, however, it 
usually begins to subside toward the end of the first week. 
The ecchymosis thereupon leaves its usual mark in the 
skin in the form of well-known color changes, and the ten- 
sion of the skin relaxes. If the swelling is very great, the 
skin over the seat of fracture sometimes presents vesicles 
and blebs filled with serum, which, however, do not affect 
the normal course if the fracture is properly treated and no 
further complications declare themselves. Nevertheless 
they call for careful disinfection of the skin and an asep- 
tic dressing. 

[Secondary infection of a simple or closed fracture is a 
very rare observation, even in those cases associated with 
extensive blood extravasation. When an anesthetic has 
been given to reduce the fracture, the possibility of a post- 
anesthetic pneumonia must be borne in mind. With the 
first rise of the temperature and accompanying leucocy- 
tosis the signs of lung involvement may be so obscure 
that there will be difficulty in excluding the fracture as 
the cause. In some instances it might be safer to explore 
the fracture under cocain anesthesia, because the early 
incision, if the fracture is infected, is the most important 



GEXEEAL CONSIDERATIONS. 45 

one in the ultimate result. It can do no harm if the frac- 
ture is not infected. I have had one such experience. 
Later in the progress of a simple fracture pyogenic osteo- 
myelitis is very rare. In my observations it has usually 
been associated with comminuted fractures in which one 
of the fragments has become completely separated from the 
periosteum, with death from lack of blood-supply. This 
fragment undoubtedly has acted as a foreign body and 
lowered the resistance of the surrounding tissues. In 
every case observed the infection has taken place after com- 
plete healing of the fracture, and with timely and proper 
operative interference the ultimate result has not been 
affected by this late complication. — Ed.] 

The disappearance 
of this early and softer y^&^>^ 

swelling is followed 
by the formation and 
appearance at the seat 
of fracture of a harder 
spherical or spindle- Fig. 5.— Callus-formation in a recent 

shaped tumor, which fracture of the ribs, without displace- 
soon becomes almost ment. 
cartilaginous. This 

swelling gradually fades away in either direction into the 
normal outline of the bone ; it is the so-called callus. As 
it increases in density, the abnormal mobility at the seat 
of fracture diminishes. Finally, the fragments become 
actually fixed by the callus, and the fracture is said to be 
consolidated or united. 

It is a rather remarkable fact that this normal course 
is the rule. In new-born children, as well as in persons 
of advanced age, consolidation of the fracture by means of 
callus takes place. The new tissue is almost exclusively 
a product of the periosteum. The irregular laceration of 
the periosteum at the seat of fracture, with the presence of 
minute shreds of the membrane in the immediate neigh- 
borhood, probably leads to the production of a periosteal 




46 FRACTURES AND DISLOCATIONS. 

PLATE 7. 

Observation of the Repair of a Severe Fracture of the Leg 
by Means of the Rontgen Rays.— Male, thirty-three years old, 
laborer, sustained a fracture of the lower half of the leg. The diag- 
nosis was certain, the displacement of fragments marked, and the 
Rontgen rays confirmed the presence of a multiple fracture of the 
tibia. Even under anesthesia the fragments could not be accurately 
replaced (Fig. 1). Operation was accordingly resorted to, the fragment 
was exposed, and both ends secured with silver wire sutures (Fig. 2). 
The wires were later removed and excellent union resulted (Fig. 3). 

proliferation partaking of the character of an ossifying 
periostitis. In this process the bone-marrow is not alto- 
gether passive ; it also exhibits some degree of callus- 
formation (pin callus). In an ordinary fracture without 
marked displacement of the fragments we may suppose 
this callus-formation to take place about as follows : The 
outer or periosteal callus (ring callus) surrounds the ends 
of the fragments like a ferrule (ring-shaped mass of mor- 
tar), the inner or pin callus occludes the medullary cavity 
at the seat of fracture, while between the two, and uniting 
them, is the so-called intermediary callus formed by the 
bone tissue itself. 

In marked displacement of the fragments callus-forma- 
tion is, of course, much more abundant. Considerable 
masses of callus are often built in, as it were, like masonry 
between the ends of the fragments. In the case of chil- 
dren callus-formation is least marked, the periosteum, as a 
rule, is not torn, and forms a sheath about the seat of 
fracture, at the same time guarding the fragments from 
displacement. 

[It is to be remembered that callus-formation is very 
slight in some fractures ; for example, the olecranon, the 
patella, and the neck of the femur. For this reason in 
fractures of the patella and olecranon, unless we can get 
absolute approximation we resort to an early perfect 
approximation of the fragments with some form of suture ; 



GENERAL CONSIDERATIONS. 47 

silver wire is preferred. For the same reason one should 
never interfere with the impaction in a fracture of the neck 
of the femur. — Ed.] 

In compound fractures )ieerosis of one or both ends of 
the fragments sometimes takes place. In this traumatic 
form of necrosis, as in osteomyelitis, a line of demarcation 
appears between the dead and the living bone. The liv- 
ing portion becomes the seat of rarefying osteitis which 
after a variable period of time, ranging from two to six 
months according to the age of the patient and the bone 
involved, leads to complete separation of the dead bone, 
the so-called sequestrum. Meanwhile an ossifying perios- 
titis is manufacturing new bone, and as a rule in sufficient 
abundance to bring about consolidation of the fracture by 
union of the newly formed bone tissue from either side, so 
that complete recovery finally ensues after separation of 
the sequestrum. 

[Osteomyelitis with its accompanying necrosis in com- 
pound fracture can usually be prevented or inhibited by 
early and proper operative intervention and the intelligent 
treatment of the wound. At the operation the two most 
important points are : first, the disinfection ; second, care 
in preserving the circulation of the bone. Completely 
separated fragments of the bone should be removed. 
Every effort should be made to preserve the periosteal 
attachment of the remaining bone. In the treatment of 
the wound we must make the proper decision whether it 
should be treated as an open or as a closed wound. If 
we feel that there is no infection and no necrosis of tissue, 
we should close the wound, but when" it is necessary to 
leave the wound open, it is remarkable how infection can 
be combated and osteomyelitis and necrosis inhibited by 
the subsequent open treatment of the wound. Union is 
always delayed, and the case demands long fixation. I 
have observed a few cases in which the open fracture 
healed under direct observation by granulation without 
any gross necrosis ; osseous union resulted. — Ed.] 



48 FRACTURES AND DISLOCATIONS. 

PLATE 8. 

Repair of Fractures; CaIlus=formation.— Fig. 1.— Cross-sec- 
tion of the humerus, showing a fracture. Slight angular displace- 
ment. At the seat of fracture we see the old compact bone of the 
fragments connected by a scanty mass of callus which has again 
assumed the character of compact bone. The medullary cavity is pat- 
ulous, though somewhat encroached upon by a few plates of spongy 
bone at the seat of fracture. (From the Pathologic Institute at 
Grief swald. ) 

Fig. 2. — Cross-section of the tibia showing an angular fracture. The 
marked displacement and lateral apposition of the fragments is recog- 
nized. The original compact bone of the cortex has assumed a more 
spongy character, the medullary cavity is interrupted by the cortical 
portions of both fragments, and a thick mass of new bone is interposed 
between them. (From the Pathologic Institute at Greif swald. ) 

Fig. 3. — Specimen from a severe compound fracture of the thigh. 
The infection of the wound has led to necrosis of the ends of the frag- 
ments in their entire cross-section, followed by the formation of 
sequestra which separated after months. The limb was finally ampu- 
tated because firm union of the bone was despaired of. 

In figure 3 a one of the fragments is represented in section, afford- 
ing a good view of the deposits, the beginning resorption in the com- 
pact bone, and the occlusion of the medullary cavity by masses of 
spongy tissue. 

Figure 3 b shows a complete section of the fragment and the 
sequestrum belonging to it. The sequestrum appears like a piece of 
macerated bone with jagged projections. The other end is surrounded 
by the contiguous piece of bone ; the normal appearance of the latter 
is altered by delicate deposits on its surface which become more 
abundant toward the sequestrum and take on the character of stalac- 
tites. 

Figure 3 c shows on one side the sequestrum with the fractured 
surface, and on the other side the jagged projections formed during 
the slow inflammatory processes ending in separation. (From the 
author's collection.) 



It was formerly customary to distinguish between pro- 
visional and permanent callus-formation (Dupuytren), but 
in the light of our present knowledge we can only speak 



Tab. 8. 



'4.th . 




Fig.<3 b 






Fig.J 






Z*#l Anst. E ReLeMwld, Winch e 



GENERAL CONSIDERATIONS. 49 

o{ provisional and permanent conditions in the repair of 
fractures in so far as, after the repair of a fracture in the 
ordinary sense, various changes continue to take place for 
an indefinite period of time, lending a more permanent 
character to the anatomic appearance of the seat of frac- 
ture. In other words, the seat of fracture continues to 
undergo change even after firm union of the bone has 
taken place. The callus, which at first is abundant and 
spongy in character, becomes reduced in quantity and its 
density increases until it gradually assumes the character 
of a compact mass of bone. Those portions of the callus 
and of the fragments that have not been utilized in the 
mechanical repair of the fracture undergo gradual resorp- 
tion, the bone retaining only as much as it needs for the 
performance of its mechanical function. Even the medul- 
lary canal may regain its integrity. These processes of 
absorption and ossification require a great deal of time. 
The illustrations found on Plate 8 show the outer callus, 
the occlusion of the medullary cavity by the inner callus, 
callus-tissue of a spongy and compact character, and the 
resorption of old compact masses of bone. 

Complications of Fractures and Their Treatment 

Fat embolism has already been mentioned. While the 
resorption of small masses is not attended by danger, the 
absorption of large masses of fat may be a very serious 
matter ; even fatal. The fat is derived from the lacerated 
bone-marrow and possibly from the injured adipose tissue 
at the seat of fracture. Fat, which at body-temperature is 
fluid, may enter directly into the lacerated veins of the bone 
and thus reach the circulation, or it may be absorbed and 
carried away by the lymphatic channels. The fat thus 
enters the circulation and leads to fat embolism in the 
capillaries of the lungs. If the fat passes through the 
pulmonary capillaries, it enters the arterial circulation and 
may lead to embolism in the various organs (general fat 
4 



50 



FRACTURES AND DISLOCATIONS. 



embolism). In fatal cases extensive fat embolism in the 
lungs, in the central nervous system, and in the capillaries 
of the greater circulation has been demonstrated. The 
treatment consists in stimulating the action of the heart so 
as to facilitate the excretion of the fat by the kidneys. 

Thrombosis of a vein and embolism, though rare, con- 
stitute a very dangerous complication of subcutaneous frac- 
tures. Cases have been reported in which the repair of a 
fracture was suddenly interrupted by the occurrence of 
sudden death with symptoms of asphyxia. At the necropsy 

embolism of an artery 
derived from a throm- 
bus at the seat of 
fracture was found. 
In other cases which 
ended in recovery the 
diagnosis of embolism 
of the pulmonary 
artery was made from 
the clinical symptoms. 
Thrombosis in the 
region of fracture often 
produces an edematous 
swelling of the injured 
extremity. This acci- 
dent has been observ- 
ed most frequently in 
fractures of the lower extremity, usually in the third week. 
It occurs sometimes in relatively mild cases, as instanced 
recently in the case of a fracture of the patella. 

[As yet we have discovered no preventive treatment for 
thrombosis and phlebitis. It is usually not a fatal or 
serious complication, but it is a very uncomfortable one, 
and interferes with the function of the limb for many 
months. The diagnosis should not be difficult. It is a 
late complication, associated with great pain and swelling 
of the limb, and not infrequently with some fever. If 




Fig. 6. — Fat emboli in the pulmonary 
tissue. Recent preparation treated with 
a solution of caustic soda. The fat is 
seen within the capillaries and in free 
globules. 



GENERAL CONSIDERATIONS. 51 

the patient is out of bed, the reclining position should 
immediately be resumed ; the limb should be elevated ; the 
dressing should be frequently changed and applied with 
great care and less snugly than usual ; later, about the 
second week, gentle massage should be instituted, and pas- 
sive motion of the joints. Involvement of the joint in 
the general phlebitis is not uncommon, even with resulting 
ankylosis, if not properly treated. — Ed.] 

Injuries to blood-vessels are not so very uncommon ; 
they may lead to extensive hemorrhages if the artery has 
been injured, or to the formation of aneurysm or to gan- 
grene. The anterior and posterior tibial arteries are the 
ones most commonly injured. The subject of gangrene 
from tight bandaging will be discussed later. 

[The possibility of vessel injury in fracture is a com- 
plication most frequently overlooked. Gangrene of the 
limb much more often follows this complication than tight 
bandaging, although in many instances the bandage and 
the surgeon have borne the odium of the result. It is 
especially important to bear this in mind in a suit for mal- 
practice. The subject has recently been fully discussed by 
Hertzog, 1 Schultz,* Boetticher, 3 mid Bloodgood.*— Ed.] 
Injuries to nerves may occur in fractures from a 
variety of causes. A nerve-trunk, such as the ulnar or 
external popliteal, for example, being closely applied to the 
bone may be injured in direct fractures by the same force 
that produces the insult ; or a nerve-trunk may be injured 
by the displaced fragments (interposition) ; or, finally, the 
nerve may be compressed by, or actually included in, the 
callus-formation. The symptoms obviously depend on 
the cause and the distribution of the injured nerve. 
Operative intervention, consisting in freeing the injured 

1 Beitrage zur klin. Chirurgie, 1899, Bd. xxm, p. 643. 

2 Deutsche Zeitschrift fur Chirurgie, 1897, Bd. xlvi. 

3 Ibid., 1898, Bd. xlix, p. 297. 

*! Maryland Medical Journal, September, 1900; and Progressive 
Medicine, December, 1899, p. 190. 



52 



FRACTURES AND DISLOCATIONS, 




nerve from the surrounding mass of callus, may be con- 
sidered and has often been followed by complete recovery. 
[Operative intervention for nerve injury associated with 
fracture is unfortunately frequently 
delayed. At the first examination we 
should always search for nerve injury. 
If the nerve is severed, it should at 
once be found and the ends reunited. 
When later, in the healing of the frac- 
ture the nerve becomes compressed by 
the scar tissue or the callus, the indi- 
cations for operation are not so clear, 
because observations have demonstrated 
that nerve function is restored later 
when the scar tissue and callus are 
absorbed. This, however, does not 
always take place, and surgeons, are 
frequently called upon to operate. 
Without much doubt a more careful 
study of the cases would in many in- 
stances lead us to an earlier operation. 
The prognosis for the restoration of the 
function of the nerve after suture or 
after its separation from its surround- 
ing and compressing scar tissue or 
callus is always good, though the 
restoration of complete function does 
not usually take place for a year. 
We should perform the operation even 
in those cases when the interval of 
time since the injury is a long one, 
even a number of years. In these 
cases of long duration the prognosis is 
less favorable, but there is always a possibility that the 
nerve will regenerate. — Ed.] 

Delayed Callus-formation (Delayed Union). — Al- 
though excessive development of callus and, rarely, actual 



Fig. 7. — Club- 
shaped enlargement 
of the musculospiral 
nerve, surrounded 
by an abundant 
mass of callus, in 
fracture of the hu- 
merus. The nerve 
has been exposed by 
chiseling away the 
edge of the bone. 
The paralysis ulti- 
mately disappeared. 
(After Oilier, sup- 
plemented by the 
author's own obser- 
vation.) 



GENERAL CONSIDERATIONS. 



53 




tumors, such as osteomata, enchondromata, and sarcomata 
are observed, the process of callus-formation is occasion- 
ally much delayed. The cause of this 
is rarely ascertainable. From a prac- 
tical standpoint it is important to 
know that in such cases conservative 
expectant treatment, supplemented by 
the use of suitable auxiliary procedures, 
will as a rule be followed by firm union, 
thus avoiding the production of a false 
joint. These auxiliary procedures in- 
clude general tonics, regulation of the 
diet, exercise, and the application of 
suitable dressings allowing the broken 
limb to hang free. Good results are 
often obtained by inducing venous 
hyperemia at the seat of fracture by 
means of a moderately tight rubber 
bandage applied above the fracture, 
the limb below the seat of fracture 
being at the same time protected by 
means of a bandage (Fig. 8). As the 
author has shown, the venous hyper- 
emia can in this way be easily confined 
to a definite point, and by regulating 
the compression of the elastic bandage 
the dosage, so to speak, can be con- 
trolled. 1 This procedure has been 
especially recommended by Bier in the 
treatment of tubercular affections of 
the extremities by means of venous 
hyperemia, and has been commented 
upon by various authors. In fractures 
showing delayed or insufficient callus- 
formation it works very well, and can 

1 Compare Helferich, Ueber kiinstliche Vermehrung der Knochen- 
neubildung, Archiv f. klin. Chir., 1887, vol. xxxvi. 



Fig. 8. — Author's 
method of inducing 
venous hyperemia 
at the seat of frac- 
ture. A strip of felt 
is interposed be- 
tween the skin and 
the rubber band 
which is fastened by 
means of an artery 
forceps. The lower 
part of the leg is 
protected by a ban- 
dage, so that the ef- 
fect of the hypere- 
mia is entirely con- 
fined to the seat of 
fracture. 



54 FRACTURES AND DISLOCATIONS. 

of course be combined with the various methods of im- 
mobilization. A more energetic operative manipulation 
consists in rubbing the fragments of the bone one against 
the other under anesthesia or in driving nails into the ends 
of the fragments to set up irritation and more energetic 
reaction. 

[The subject of delayed union in fracture is a very im- 
portant one. As a rule, it is due to faulty position, 
wide separation of fragments, or the interposition of soft 
parts, very rarely to new-growth formation in the callus. 
These conditions demand immediate operative interference. 
Now and then, when the fragments are in perfect apposition, 
firm union may be delayed. The best treatment in the 
latter is undoubtedly the so-called ambulatory combined 
with frequent change of dressing and massage ; in addition, 
we should seek for the cause in the general health of the 
patient. If anemic, they should be given iron and tonics ; 
if syphilitic, the proper therapeutic remedies. They should 
be encouraged to live outdoors as much as possible. In 
the case of a syphilitic man with a fracture of the shaft of 
the tibia in the middle third, and a second similar case 
with a fracture of the shaft of the femur, upper third, solid 
bony union did not take place for a year, but our persist- 
ence in the ambulatory treatment with proper fixation was 
followed by a perfect result in each instance. Such 
observations are rare. We more frequently observe de- 
layed union after operation for badly united fractures or 
in cases of non-union because of the overriding of fragments 
or the interposition of soft parts. The danger of delayed 
union increases with the interval of time since the original 
injury. This seems to be due to a process of osteosclerosis 
usually combined with an anemic condition of the ends 
of the bone in which the marrow spaces between the scle- 
rotic areas become very fatty, a condition called lipomasia. 
The osteosclerosis is probably a secondary condition to the 
callus-formation, and the lipomasia is the result of the poor 
circulation which is always present in unused extremities. 



GENERAL CONSIDERATIONS. 55 

Both conditions inhibit callus-formation and its proper 
ossification, so that after the operation the properly ap- 
proximated fragments very slowly throw out callus, and 
the firm ossification of this new callus may be delayed for 
months, even a year, and in some few instances firm bony 
union is never accomplished. Nevertheless, bearing these 
possibilities in mind, we should persistently continue the 
proper treatment. In the majority of instances a good 
result will be obtained. — Ed.] 

The term pseudarthrosis or false joint is employed 
to describe the formation of a new joint which occurs 
when firm union fails to take place. Further details in 
regard to the subject will be found under the head of 
Treatment. It may here be briefly stated that we dis- 




Fig. 9. — Fibrous pseudarthrosis of the ulna (after Bruns). The 
fragments are connected only by bands of connective tissue. 

tinguish tw r o forms of false joint, a fibrous pseud arthrosis y 
and a "true" pseudoarthrosis; i. e., the formation of a joint 
with articular cleft and a capsule. 

The formation of a false joint may be due to general or 
to local causes. Among general causes syphilis, general 
debility, etc., are the most important. Various circum- 
stances operating at the seat of fracture itself may lead to 
the formation of a false joint. Thus, for example, severe 
contusion at the seat of fracture, such as occurs in grave 
direct fractures, especially if they are compound. 

In other cases a false joint may result in spite of normal 
or even exaggerated callus-formation, either because of the 
interposition of soft parts or marked overriding of the 
fragments. 



56 



FRACTURES AND DISLOCATIONS. 




Fig. 10. — False joint after fracture of the humerus. The extremity 
of one of the fragments is slightly club-shaped, while that of the other 
is flattened out in the shape of a shallow cup. The two fragments 
articulate within a true capsule showing a villous formation (specimen 
from the cadaver ; author's own observation). (Compare Fig. 11.) 




Fig. 11. — Specimen of a well-developed false joint. Specimen 
shown in figure 10 after maceration. On the posterior aspect of the 
lower fragment of the humerus a kind of cup-shaped expansion is 
seen which articulates with the extremity of the upper fragment ; the 
latter has undergone but slight alteration. The cup-shaped expansion 
is formed entirely by periosteal deposit, the medullary cavity is almost 
completely occluded at the extremities of both fragments, including 
the free lower extremity of the lower fragment. 



GENERAL CONSIDERATIONS. 



57 



The interposition of soft tissue, especially of muscle- 
fibers, forms an absolute obstacle to firm union, and 




Fig. 12. — False joint of many years' standing, in the left forearm, 
from loss of bone tissue. Caused by severe fracture sustained in early 
life. Male, forty-four years of age, had a severe fall at the age of 
eight and sustained a multiple fracture of the left forearm. Several 
pieces of bone were removed. The patient was treated in clinic for 
nine months, but the arm remained practically useless. At present 
there is an obtuse-angled ankylosis of the left elbow, and the fingers 
of the left hand are undeveloped, flexed, and immovable. The 
left forearm is 11 cm. shorter than the right, and shows a false 
joint at the junction of the middle with the lower third. In the 
peripheral segment the radius is preserved, while the ulna is com- 
pletely wanting. There is an absolute want of control at the false 
joint, the peripheral segment falling down with the hand unless it is 
supported. The patient improvised a splint which enables him par- 
tially to oppose the thumb against the fingers, which are immovable. 
Cicatricial contractions are seen at the seat of fracture and at the 
elbow. It is probable that the fracture was compound, that the wound 
became infected, and that suppuration followed. Resection of the 
lower segment of the ulna ; ultimate healing of the wound with the 
production of a false joint in the radius, loss of the ulna, and anky- 
losis of nearly all the joints and tendons involved. 



58 FRACTURES AND DISLOCATIONS. 

always leads to pseudarthrosis. Interposition of muscular 
fibers is most frequently observed in fractures of the hu- 
merus and femur, and is explained by the length of these 
bones and the great liability to displacement of the frag- 
ments which readily penetrate into the surrounding mass 
of muscular tissue. The diagnosis of interposition in a 
recent fracture may be made by observing movement of 
one of the fragments during contraction of the lacerated 
muscle (rare) ; and, chiefly, by the absence of crepitus in 
spite of a marked degree of abnormal mobility at the seat 
of fracture. In such a case the fragments must be forci- 
bly replaced, if necessary by operative means, until crepi- 
tation is elicited ; the usefulness of this method is vouched 
for by the author on the strength of numerous observa- 
tions. 

High degrees of displacement — overriding of the frag- 
ments — occurs most frequently in the humerus and femur. 
In spite of abundant callus-formation from both of the 
overriding fragments ossification fails, and a pseudarthrosis 
results. 

Finally, it goes without saying that insufficient immo- 
bilization of the fracture greatly favors the production of 
a false joint. 

The correction of a pseudarthrosis may be achieved by 
such minor interventions as rubbing the ends of the frag- 
ments together, or driving steel or iron nails into the 
bone, but only when the condition is due either to the ab- 
sence of callus-formation or to insufficient immobilization. 
If the case is one of interposition, with marked displace- 
ment at the seat of fracture and the formation of a false 
joint, the only hope of recovery lies in operative removal of 
the interposed tissues, resection of the ends of the bones, 
and proper fixation. If there has been much loss of bone 
tissue at the seat of fracture, the interposition of a piece 
of bone between the ends of the fragments by means of 
transplantation may prove successful. 

[Bone transplantation is an uncertain procedure. The 



GENERAL CONSIDERATIONS. 59 

bone flap should be taken from one or both of the frag- 
ments. Its periosteal attachments should always be pre- 
served, and if possible some muscles. The details of this 
procedure belong to the special surgery of bone operations 
rather than to a treatise on fractures. — Ed.] 

Suppuration in a subcutaneous fracture (closed), 
that is to say, suppuration of the extravasated mass of 
blood, may be the result of infection derived from some 
distant point (angina, furuncles, etc.), although not the 
slightest injury of the skin is present at the seat of frac- 
ture. In such cases early and thorough incision and 
drainage are indicated ; as a precautionary measure any in- 
flammatory area in the body should be carefully treated. 

Delirium tremens is a grave complication. Its occur- 
rence, especially in fractures of the lower extremity, calls 
for the application of heavy plaster casts reinforced by 
iron splints, and for constant supervision to prevent the 
patient, who is insensible to pain, from getting out of bed. 
Great care is necessary in the administration of anesthet- 
ics if delirium is present. As a prophylactic measure 
alcohol should be given from the beginning and insomnia 
combated by the administration of hypnotics, chloral 
hydrate being preferable to morphin. 

[In this country it is the usual practice to place the 
fractured limb in a pillow splint when the patient is suf- 
fering from delirium tremens. Properly applied, it holds 
the fracture in good position, it allows frequent inspection, 
and is more comfortable. The extreme restlessness of the 
patient increases the danger of some injury if the leg is 
incased in plaster-of-Paris. — Ed.] 

Prognosis of Fractures 

The prognosis in a simple, subcutaneous fracture is, 
generally speaking, favorable so far as life is concerned. 
The prognosis may be unfavorably influenced by grave 
accidents, such as those that have been described above, 



60 FRACTURES AND DISLOCATIONS. 

and by old age or debility of the injured person. A con- 
siderable proportion of the cases of fracture of the lower 
extremity occurring in old persons end fatally from hypo- 
static pneumonia. [In any patient in whom we fear lung 
complications some form of ambulatory splint should be 
used, and the patient at least should be allowed to sit up. 
—Ed.] 

Our knowledge of the factors influencing repair of a 
broken bone, both as regards its form and restoration of 
function, has received many additions in recent times. 
This is derived from two sources. The development of 
legislation in regard to accidents has produced valuable 
statistical information in regard to the effect of individual 
fractures on the subsequent ability of the injured person to 
earn a living. Our knowledge prior to this time has been 
summarized in the following generally accepted truths : 

Firm union is facilitated and hastened by vigorous 
health in the person affected ; slight degree of dislocation, 
permitting perfect reduction ; a method of treatment which 
leaves the seat of fracture itself free and allows a fuller 
hyperemia to take place (treatment by extension). The 
prognosis in spiral fractures, owing to extensive injury to 
the bone-marrow, and in direct fractures, on account of 
the accompanying contusion of the soft parts, is more un- 
favorable than that of transverse fractures and indirect 
fractures. Prolonged disuse of an extremity is followed by 
atrophy of the muscles and rigidity and other changes in the 
articulations. 

As the result of recent accident legislation many details 
are now more accurately known. A man who has sus- 
tained a fracture is not considered cured until he is able to 
work, hence a fracture very frequently produces permanent 
disability. A valuable paper on these questions, with 
numerous statistics, was contributed by Hanel, 1 after 
analyzing material obtained from labor unions. Of a total 
of 121 fractures of the shaft of the femur, 34 ^ ended in 
1 Deutsche Zeitschrift fur Chirurgie, vol. xxxviii, page 129. 



GENERAL CONSIDERATIONS. 61 

perfect recovery, 66^? in permanent disability ; the aver- 
age duration of treatment was 13.5 months. Of 19 cases 
of fracture of the neck of the femur, V2f proved fatal, 
V2 c /c ended in recovery, and 76 e / in permanent disability. 
Of 148 fractures of the leg, 78 f ended in recovery, 21 f 
in permanent disability. Of 32 fractures of the arm, 72 f c 
resulted in recovery; of 67 fractures of the forearm, 89 ^ 
ended in recovery. 

Somewhat better results have been reported by Loew 1 
and Bliesener. 2 The former's investigations concerned 
167 fractures of the leg; the latter* s, a large number of 
fractures of the lower extremity, treated in the Kolner 
Hospital by Bardenheuer's extension method. Jottkowitz 
furnished a statistical illustration of the favorable influence 
of mechanical after-treatment after firm union of the frac- 
ture, his figures being based on the abundant material, 
consisting especially of fractures of the leg, supplied by 
the Konigshutte Knappschaftslazarett. 3 With only a 
slight increase in the duration of treatment more recoveries 
were recorded ; and during the period of thirteen weeks 
allowed for recovery, 49 °fo of all the cases were cured, as 
against 36^ under the old system. 

The chief causes of unfavorable results and unduly 
delayed recovery observed in many cases are displacement 
of the fragments, rigidity of the immobilized joints, hyper- 
trophy of the callus, delayed consolidation (ossification), 
pressure on nerves, pain, and edema at the seat of fracture. 
The lesson to be learned from these observations is that the 
kind of treatment instituted has an important influence on 
the result. 

Our second source of information is one which has 
recently produced a revolution in surgical lore. It is the 
use of the Rbntgen rays. By the aid of this discovery it 
has been proved that even when firm union, with perfect 

1 Deut. Zeitschr. f. Chir., vol. xliv, p. 462. 

2 Ibid., vol. lv, p. 277. 

3 Deut. Zeitschr. f. Chir., vol. xlii, p. 610. 



62 FRACTURES AND DISLOCATIONS. 

restoration of function, takes place, the shape of the bone 
is not by any means always perfect ; in other words, a 
deformity remains. Interference with function, therefore, 
is not always due to deformity at the seat of fracture, 
although the deformity is a factor of some moment. The 
value of the Rontgen rays as an aid to treatment lies 
chiefly in the fact that they enable us to determine the 
kind of displacement present and to control its develop- 
ment during the period of treatment. The method should, 
therefore, always be resorted to. I consider it indispensa- 
ble in a large number of fractures to examine the seat of 
fracture with the Rontgen rays, both before and after 
replacement of the fragments ; in this way there is no pos- 
sibility of deformity appearing unexpectedly. Even in 
subcutaneous fractures the fate of the injured person is in 
the hands of the physician. Perfect restoration of the shape 
of the bone must be achieved early, either by bloodless 
methods or by replacing the fragments under anesthesia 
and, if necessary, by wiring the fragments together. 

Treatment of Fractures 

The object is to obtain firm anion of the fragments without 
displacement and without loss of function. To accomplish 
this, two things are necessary : accurate replacement of the 
fragments and a suitable dressing. 

Reduction almost always necessitates the presence of 
one or two assistants who exert extension and counter- 
extension while the surgeon replaces the fragments by 
appropriate manipulations, such as lateral pressure and 
flexion or extension of the limb. Speed and accuracy 
in reduction depend on the surgeon's general knowledge 
of the typical displacement occurring in the fracture, and 
his special knowledge previously obtained by examining 
the position of the fragments. In reducing an incomplete 
fracture with angulation of the fragments, the fracture is 
often converted into a complete one. Sometimes reduction 



GENERAL CONSIDERATIONS. 63 

is exceedingly difficult and cannot be effected without anes- 
thesia. The special obstacles to reduction are : excessive 
displacement of the fragments, especially of bony promi- 
nences that have been broken off; interposition of soft 
parts ; fixation of the sharp ends of the bone in the soft 
parts (perforation of the skin from within) ; impaction of 
the fragments, in which case it is not always proper to sepa- 
rate them ; and certain unusual complications, such as shat- 
tering of the bone, a complicating luxation, etc. 

Too much stress cannot be laid on the importance of 
perfect reduction; it is often the deciding factor in the 
prognosis, and as it cannot always be effected even under 
anesthesia, it is justifiable with our present aseptic methods 
to cut down on the bone even in a subcutaneous fracture 
for the purpose of obtaining complete reduction, and, if 
necessary, wiring the fragments in their corrected position. 

Dressing. — Since the object of the dressing is to place 
the fragments at rest, it must include the broken bone and 
the tico contiguous joints. The materials used are pillows, 
splints, wire gutter-splints, and more complicated appara- 
tus. In a case of emergency, and during the first trans- 
portation of the patient, a broken arm may be bound fast 
to the thorax ; in a case of fracture of the lower extremity 
the sound limb may be used as a temporary splint. The 
commonest surgical dressings at present in use are those 
that harden after their application, especially plaster-of- 
Paris bandages. Splints or extension by means of weights 
are also employed. 

While it is undoubtedly true that good results may be 
obtained in the treatment of fractures in a variety of dif- 
ferent ways or by the exclusive use of any one of the vari- 
ous methods of dressing, provided the surgeon possesses 
some measure of skill and experience, there are nevertheless 
certain fundamental principles that should be observed in 
order to avoid unpleasant consequences. 

The choice of the method in the beginning is deter- 
mined by the position of the fragments after reduction. 



64 FRACTURES AND DISLOCATIONS. 

If reduction has been correctly carried out and the result- 
ing position can be maintained, the subsequent treatment 
consists solely in retaining the fragments in good position. 
This may be done by means of any firm bandage, such as 
splints, plaster bandages, etc., and is usually quite easy in 
transverse fractures and in many oblique fractures. If, 
however, the fragments have not been successfully re- 
placed and there is more or less tendency to secondary dis- 
location ; if, for instance, one or the other fragment is 
subject to the unopposed action of a muscle, especially in 
oblique fractures, the aim of the treatment should be 
to bring about, if possible, a permanent condition like 
that Avhich is produced temporarily when a fracture is 
properly reduced by traction and countertraction ; in such 
cases an extension apparatus is indicated. Extension 
is almost always effected by means of weights permanently 
attached to the limb and varying in size with each indi- 
vidual case, or by means of the tension exerted by elastic 
bands. The extension treatment is, of course, applicable 
to the first group of cases as well, and has the advantage 
of allowing free access to the seat of fracture ; but it re- 
quires more constant supervision on the part of the surgeon 
and, as a rule, keeps the patient in bed longer than any 
other method of treatment. 

The treatment by means of splints and plaster-of-Paris 
also requires careful attention and the strict observance g of 
certain rules. The older physicians not infrequently 
applied a plaster bandage to a recent fracture at their first 
visit and left the bandage in place for weeks until union 
was supposed to have taken place. This procedure is to be 
condemned absolutely, for it necessarily results in more or 
less deformity. In applying the primary dressing the 
surgeon must keep in mind that the limb will be enlarged 
at the seat of fracture by swelling of the soft parts which 
is often considerable ; hence, to allow room for this 
swelling to take place, the first dressing must contain 
plenty of padding. It must, of course, be properly 



GENERAL CONSIDERATIONS. 65 

applied, and must include the contiguous joints, but it 
should consist largely of loose material such as cotton- 
wool, so as to allow for the expected increase in size. 
[Pieces of blanket properly folded undoubtedly make the 
very best padding material, not only to pad splints, but 
in the form of a roller bandage beneath the plaster cast 
(Halsted).— Ed.] 

In the absence of special indications the first change of 




Fig. 13.— Gangrene after simple fracture of the leg, due to tight 
bandaging. The primary dressing with splints was left in place for 
twenty-three days in spite of bluish-red and, later, black discolora- 
tion of the toes, and violent pain. The bones of the leg below the 
line of demarcation are seen to be macerated. The foot is mummified 
and held together by the desiccated ligaments. This is the condition 
found fourteen months after the injury (after Bruns). [Gangrene is 
less frequently caused by tight bandages than by an overlooked injury 
to the arteries with rupture or thrombosis. — Ed.] 

dressing should take place on the eighth day. By that 
time the swelling will have at least partially subsided and 
the dressing, becoming looser, might permit displacement 
of the fragments. The second dressing is then applied 
over the seat of fracture with little or no padding, after 
the position of the fragments has been carefully ascer- 
tained. I prefer the wood-felt (Holzfilz) manufactured by 
Hermann in Heidenheim, as it is both soft and firm 
5 



66 



FRACTURES AND DISLOCATIONS. 



and keeps the skin dry. This second dressing should 
again be changed about a week later ; that is to say, the 

second change of dressing 
should take place about 
two weeks after the in- 
jury. By that time the 
swelling has disappeared 
completely, and although 
callus-formation has 
begun, there is still some 
movement at the seat of 
fracture, so that a final 
correction of the position 
can easily be made. 
This third dressing may 
in some cases be left on 
until complete union has 
taken place. Finally a 
light and removable pro- 
tective bandage should be 
worn as long as may be] 
necessary in the indi- 
vidual case. It should 
Fig. 14.— Paralysis and contracture consist preferably of light 
of the muscles of the forearm due to splints or a cut plaster- 
ischemia, in a young man seventeen of-Paris or silicate of 
years of age, following fracture of the 
lower end of the humerus ten years 
before. The primary dressing con- 
sisted of a closely fitting plaster-of- 
Paris cast. [The cause of the muscu- 
lar contraction in this case was prob- 
ably due to an interstitial myositis recently injured limb 
(Tillman), in which the muscle is should not consist of a 
replaced by scar tissue.— Ed.] circular plaster-of-Paris 

bandage. Splints are 
very much to be preferred. Failure to observe this rule 
is responsible for many disastrous results. A tight 




lime cast. 

Unless it is especially 
indicated and the patient 
can be examined daily, 
the first dressing of a 



GENERAL CONSIDERATIONS. 67 

plaster-of-Paris bandage has in a number of cases led to 
compression at the seat of fracture, producing ischemia, 
paralysis, and contracture or even gangrene of the entire 
extremity, and many a surgeon has been held responsible 
for such results and gotten himself into serious trouble. 
All the cases of ischemic paralysis and contracture 




Fig. 15.— Fixation bandage with two padded strips of lead, bent so 
as to conform accurately to the shape of the arm flexed at a right angle 
at the elbow. The illustration shows the upper extremity of the 
posterior splint being fixed by the bandage. 

(Volkmann) that I have seen were due to this practice of 
dressing a recent fracture with plaster-of-Paris. The pro- 
longed interference with the blood-supply of the muscle 
leads to disintegration of its elements, the muscle loses its 
elasticity and becomes shortened and rigid (contracture). 
The irritability of the nerves remains intact, while that of 



68 FRACTURES AND DISLOCATIONS. 

the muscle-fibers disappears more or less completely, de- 
pending on the severity of the case. 

The best splints for use in the treatment of fractures 
are flexible metal splints, or plaster-of-Paris splints pre- 
pared for each case (Beely ? s combination splints of plaster- 
of-Paris and hemp). Of the former, I prefer either the 
wire splints proposed by Dr. Cramer, or narrow padded 
strips of lead of varying length, width, and thickness. 
The latter may be padded with cotton and a covering of 
gauze, and kept on hand ready for immediate use. AVith 
the aid of two such strips and a few bandages a broken 
limb can at once be fixed in any desired position. These 
strips, which are used in the Munchener Poliklinik and 
in Greifswald, and have recently come into vogue here, 
are, as I know, being used daily by many of my own 
students. 

The plaster-of-Paris dressing is not by any means to be 
condemned wholesale ; on the contrary, it is an excellent 
bandage for holding the fragments in place after the 
swelling at the seat of fracture has subsided. It is par- 
ticularly useful in view of the modern treatment by fre- 
quent massage of the seat of fracture, especially when it 
is cut down each side with a saw so as to be separated into 
two gutters which are easily fastened together w T ith strips 
of adhesive plaster and secured with a few turns of a 
roller bandage. 

[This criticism of plaster-of-Paris as a primary dressing 
in fractures is a very just one. One inexperienced in the 
treatment of fractures and in the use of plaster-of-Paris 
should never use this as a first dressing. On the other 
hand, as we become more experienced we use plaster-of- 
Paris more frequently as a primary dressing. 

I believe most surgeons and practitioners err on the side 
of too infrequent rather than too frequent dressings in frac- 
tures. The second dressing should always be made with- 
in the first six to ten days, because within this time it will 
be possible to correct any displacement. The advantages 



GENEBAL CONSIDERATIONS. 



69 



of more frequent dressings are : It allows the bathing and 
rubbing of the skin, so important in maintaining a better 
circulation ; it decreases the danger of atrophy or inflam- 
mation of the muscles from continuous pressure, and the 
danger of pressure necrosis of the skin over the more ex- 




Fig'. 16. — Plaster-of -Paris dressing cut down the side with a saw. 



posed bony prominences, and where pads have been used 
to exert pressure in certain forms of fractures. In frac- 
ture of the leg the possibility of pressure necrosis over the 
tendo A chillis, over the malleoli, and across the dorsum 
of the foot must always be borne in mind. This is fre- 
quently neglected, especially in inexperienced hands. Not 
only should these points be 
carefully protected by pad- 
ding, but they should be 
frequently inspected. The 
pressure spots at the position 
of the pads in Colles' frac- 
ture are also frequently ob- 
served in the hands of inexperienced practitioners. Until 
one's experience in the dressing of fractures has become 
large, and until one is quite familiar with the application 
of the different dressings, early inspection after the first 
dressing (two to four days) and more frequent subsequent 
dressings will practically eliminate the dangers and corn- 




Fig. 17. — Saw for cutting plaster- 
of-Paris dressings. 



70 



FRACTURES AND DISLOCATIONS. 



plications just mentioned. Eternal vigilance is a good 
rule in fracture dressings. — Ed.] 

For the padding of a plaster-of-Paris dressing I use 
only the tricot sleeve-bandage, which can be made to lie 
perfectly smooth over the extremity. This sleeve-bandage 




Fig. 18. — Plaster-of-Paris dressing, converted into two accurately 
fitting gutters by cutting it down the side. The cut edges are bound 
with adhesive plaster. 




Fig. 19. — Showing how the hand and foot are held in the desired 
position by the tricot sleeve-bandage, while the plaster-of-Paris dress- 
ing is applied. 



has the additional advantage that the overhanging ends 
can be utilized to hold the end of the extremity, — hand or 
foot, — while the plaster-of-Paris dressing is applied, thus 
taking the place of the loops ordinarily used. 



GFXEHAL CONSIDERATIONS. 71 

In applying a fixation bandage direct pressure on the 
seat of fracture must always be avoided. Fixation is ob- 
tained not by direct pressure, but indirectly, so to speak, 
by placing the contiguous fragments in the proper position. 
Incidentally, it hardly needs to be mentioned that any 
other prominences must also be protected against pressure 
and the formation of pressure-sores. 

The use of an extension apparatus with permanent ex- 
tension by means of weights is not confined to fractures 
of the thigh. They may quite properly be employed in 
the treatment of fractures of the tipper extremity, as, for 
example, fracture of the neck of the humerus or of the 
elbow-joint, and in fractures of the vertebral column, etc. 
The technic of these dressings must be learned by actual 
practice, which can readily be obtained in any surgical 
clinic. 

Adhesive plaster is now chiefly used for extension dress- 
ings, the American elastic plaster, if necessary on a founda- 
tion of sail-cloth, being preferred, as it is strong enough 
to bear considerable weights. To avoid irritation of the 
skin I sometimes find it advisable, especially in summer, 
to reinforce — double, as it were — the long strip of adhe- 
sive plaster by interposing a strip of zinc plaster mull, so 
that the latter alone comes into immediate contact with 
the skin, while traction is accomplished by the strip of 
adhesive plaster. 

Strips of buckskin have also been used quite recently in 
extension dressings (Heusner). The adhesive material is 
made according to the following formula : 

R . Cerse flavse. 

Kesinse Damarah. 

Colophon aa 10.0 

Terebinth. 1.0 

^Ether. 

Spirit. 

01. terebinth aa 55.0 

Filter. 

This mixture, which can be kept as long as desired in a 



72 



FRACTURES AND DISLOCATIONS. 



well-stoppered bottle, is not to be smeared on the strip of 
cloth, as might be supposed, but is to be applied with an 
insufflator so as to form a thin layer on the part of the 
body which is to receive the dressing. The two strips of 
cloth, which should be about 3.5 inches wide, are then 
applied along the limb, the ends being allowed to hang 
over for the attachment of the pulley rope. The strips are 
held in place by wrapping the limb first with mull and 
then with a gauze bandage. If the part is one that cannot 
be bandaged in this way, the method cannot be used. A 
very considerable degree of traction can be applied to the 
limb by this method, which has the advantage that the 
strips of cloth can be readily removed, after the outer ban- 




Fig. 20. — Adhesive strips and elastic cloth (congress) with which ex- 
tension of any desired strength can be effected. 



dages have been cut, and used a second time. The skin 
must be carefully washed with soap. 

In addition, some practical arrangement is needed for 
attaching the weights, such, for example, as a ring tied to . 
the end of the strips, into which may be inserted the ring 
or hook attached to the cord that supports the weights 
(sandbag, bricks, etc.). Chafing of the limb must be 
avoided as much as possible by the use of a sliding foot- 
rest, etc., and by placing a tightly wound roller bandage 
or small wooden rollers under the limb. 

The extension method is used in the treatment of frac- 
tures of the long bones. It is especially recommended by 
Bardenheuer. This surgeon uses lateral as well as longi- 
tudinal traction, and gets very good results (see page 61). 



GENERAL CONSIDERATIONS. 73 

Many other surgeons, to my personal knowledge, have 
worked up the technic of the extension method and prefer 
it in the treatment of fractures of the extremities. Blies- 
ener's article x contains detailed descriptions of all the ex- 
tension dressings used by Bardenheuer. 

The effect of traction or pressure can also be obtained 
with the aid of pieces of elastic bandage, rings, etc., in- 
serted in the dressing. A combination of adhesive strips 
and a piece of elastic cloth, as suggested by Thiersch, is 
both convenient and effective, and is being employed quite 
extensively. I frequently use elastic strips of this kind, 
especially in the treatment of fracture of the clavicle. 

Other methods are now in vogue for the treatment of 
certain fractures ; but while they may give excellent 
results in the hands of specialists, they are hardly to be 
recommended to the general practitioner. There is no 
doubt that primary bloody suture of the fragments in 
fracture of the patella gives excellent results in the hands 
of a trained surgeon ; or that the treatment o'f fractures of 
the lower extremities by the ambulatory method is fre- 
quently successful ; and it is true that in the treatment of 
typical fractures of the lower radial epiphysis it is recom- 
mended to discard bandages altogether and treat the 
fracture by simple position in a mitella ; but in general 
practice these and other similar methods are, in my judg- 
ment, out of place. 

The so-called ambulatory method has recently gained a 
great number of adherents. For my part, I still adhere 
to the principles that I have just now outlined: The 
ambulatory method may yield very good results in impor- 
tant fractures of the lower extremities, but the technic of 
applying the cast is difficult and the dressing requires 
constant, careful supervision as long as it is worn ; in other 
words, the danger of complication interrupting the course 
of recovery is greater in the ambulatory than in any of the 
other methods in ordinary use. 

1 Deutsche Zeitschr. f. Chir., vol. LV, p. 277. 



74 FRACTURES AND DISLOCATIONS. 

On the other hand, the ambulatory method has the fol- 
lowing advantages : Inflammatory diseases of the respira- 
tory organs, such as bronchitis or hypostatic pneumonia, 
are rarer even in old subjects; delirium tremens even is 
said to be less likely to develop ; it is the best means of 
avoiding atrophy of the muscles and rigidity of the joints ; 
the callus-formation is abundant, and it is said that insuffi- 
cient callus-formation is very rare when this method is 
employed. While some authorities reject the ambulatory 
method altogether, and others use it as soon as possible 
after the injury, I often follow a middle course in my 
clinic. After the swelling has subsided and the fragments 
are in good position, a firm bandage is applied and the 
patients are allowed to walk about at the end of the sec- 
ond or third week. At the beginning the pain of putting 
the foot to the ground will be materially lessened if some 
form of walking apparatus, like the " walking chairs " of 
children, is employed. 

After the fracture has become firmly united, the after- 
treatment is of the greatest importance for restoring the 
function of the injured extremity. In this respect there 
has been a marked improvement in recent times and much 
more is done to achieve a good result. Massage and pas- 
sive movement to combat the stiffness of the joints due to 
prolonged fixation may, with proper care, be begun as 
early as the date of the first change of dressing. After 
the fracture has become united, both these procedures 
assume a very important role. At the same time warm 
baths, needle douches, the use of certain kinds of bandages, 
and especially medico-mechanical apparatus, are of the 
greatest value. 

The treatment of joint fractures calls for special con- 
sideration. In a joint fracture the injury to the articular 
process of the bone leads to grave injuries of the joint 
itself, the capsule of which becomes filled with extrava- 
sated blood. This class includes the typical fractures of 
the radius, fracture of the ankle (Pott's fracture), and frac- 



GENERAL CONSIDERATIONS. 75 

ture of the surgical neck of the humerus. It is in these 
cases that it is most difficult to get firm union of the bone 
with a good movable joint. The dressing in these injuries 
must be changed every second or third day for the first 
two weeks, and later every day. To facilitate the resorp- 
tion of the blood, if it has not been removed by puncture, 
moderate pressure and massage with passive movements 
at each change of dressing are advisable from the very 
beginning. The extremity must be fixed in various posi- 
tions ; active movements should be encouraged as early as 
possible, and mechanical apparatus may be employed. A 
treatment of this kind gives the physician a great deal 
of trouble, for which, however, he is amply rewarded if 
he can achieve union of such a fracture with a good mov- 
able joint. 

A similar mode of treatment has been recently recom- 
mended by many physicians for all kinds of fractures. It 
is, however, unnecessary and cannot be carried out, espe- 
cially in large practice. 

[AVolff 1 recommends extension in fractures about the 
elbow-joint, and gives an illustration of an apparatus which 
not only produces extension, but allows frequent changes 
in the position at the elbow-joint. Similar mechanical 
devices have been devised for fractures about the knee and 
ankle. The apparatus is expensive ; one must have a 
large assortment, or they must be made for each case. 
I agree with the author that the results obtained are no 
better than those in which simpler methods have been 
employed . — Ed. ] 

In conclusion, a few words in regard to badly united or, 
better, unfavorably united fractures. Notwithstanding the 
exercise of the greatest care, it may occasionally happen 
that the physician is not quite satisfied with the result of 
his treatment; besides, many cases of deformity due to an 
old fracture have to be treated, partly because of the folly 
and disobedience of patients, and partly because of the 
1 Deutsche Zeitschrift fur Chirurgie, 1900, Bd. liv, p 287. 



76 



FRACTURES AND DISLOCATIONS. 



bungling work of quacks. In all such cases no time 
should be lost in correcting the deformity, by violent means 
if necessary. To accomplish this the bone may have to 
be broken artificially with the aid of an osteoclast, or 
osteotomy may be required. After the operation a correct 
position of the fragments is secured by manipulation and 
maintained by permanent extension by means of weights. 
The proper position is to be maintained until firm union 
again takes place. Operative intervention is distinctly 
indicated also in badly united joint fractures. 

It has been pointed out repeatedly that the position 

of the fragment can be 
constantly controlled by 
means of X-ray pictures 
during the course of 
treatment. Accord- 
ingly, I find that I now 
resort to operation much 
earlier than formerly, 
either in order to re- 
place the fragments 
more accurately or for 
the purpose of wiring 
the fragments together. 
The success I have had 
in such cases impels me 
to resort to operative 
intervention more and 
more. Such operations 
are to be carried out according to generally accepted rules, 
and their description does not belong to the scope of this 
work. It is important, however, that every physician who 
treats patients with fractures should realize his respon- 
sibility from the beginning, and should remember that 
with our present knowledge of diagnosis and therapeutic 
methods a good result can and must, as a rule, be ob- 
tained in the treatment of fractures. [With the present 




Fig. 21. — Rizzoli's osteoclast. 



GEXEEAL CONSIDERATIONS. 77 

more perfect technic a surgeon should never hesitate to 
operate in a ease of fracture. In badly united fractures 
it is much better to operate than to use great force in 
an attempt to refracture. If the badly united fragments 
cannot be broken with the use of moderate force, it is 
a much wiser and safer procedure to expose the bone 
by incision and separate the fragments with a chisel, 
because it allows us to control absolutely the line of frac- 
ture. The use of greater force by means of an osteoclast 
(Fig. 21) is not free from danger, and we cannot always 
control the line of fracture. — Ed.] 

DISLOCATIONS 

The extent of the movements in normal joints is in 
many cases limited. In every joint there is some pro- 
vision which prevents the movement from going beyond 
a certain definite limit. In some of the joints this inhib- 
ition is effected by the shape of the bones, in others by the 
action of ligaments, and in a third class by the action of 
muscles. We therefore speak of muscular, ligamentous, 
and bony inhibition of joints. Bony inhibition is absolute, 
while muscular inhibition varies according to the elasticity 
and extensibility of the muscles concerned. As examples 
may be mentioned the great mobility of the wrist in piano 
performers, and the contortions of so-called india-rubber 
men, which can only be achieved by exercise directed 
toward the diminution of muscular inhibition. 

There is a limit to the motion of any joint, beyond 
which, if motion is continued, injury to the articular appa- 
ratus, a laceration of the capsule or other ligaments, takes 
place ; such an injury we designate by the term sprain 
(distorsio). If the injury to the articular apparatus is severe 
enough, a dislocation (luxatio) is produced, in which the 
normal contact between the articular extremities of the two 
bones is completely abolished, one of the extremities with 
few exceptions being thrust more or less completely through 



78 FRACTURES AND DISLOCATIONS. 

the tear in the capsule. As in the case of fractures, we 
have traumatic, pathologic, and congenital dislocations. The 
latter depend on true developmental errors or on displace- 
ment occurring in utero. Pathologic [spontaneous] dis- 
locations occur only after marked alteration of the joint by 
pathologic processes, especially pyogenic and tubercular 
osteomyelitis and chronic hydrarthrosis with extreme dis- 
tention of the capsule and ligaments. 

[In dislocations from slight injury, especially recurrent 
ones, the possibility of syringomyelia as the cause of the 
joint changes allowing the easy dislocation should always 
be borne in mind. This is most frequently observed at 
the shoulder. — Ed.] 

Traumatic dislocations, which are the only ones that we 
shall speak of here, are produced by injuries affecting the 
joint directly or indirectly. Luxations may even be pro- 
duced by intense muscular action in sudden violent move- 
ments. 

Dislocations are, of course, more frequent in men than 
in women, and in adults up to beginning old age than in 
children. In children under ten years of age dislocations 
are extremely rare. It is worth noting that out of 100 
luxations collected by Kronlein, 92.2 were in the upper, 5 
in the lower extremity, and 2.8 in the trunk. 

Dislocations due to direct violence are rare. In this class 
the traumatism acts at the region of the joint and produces 
a dislocation ; just as a fracture is produced in a bone by 
direct violence. In the production of an indirect dis- 
location the movement of the joint is carried beyond the 
utmost limit of physiologic excursion, the normal inhibition 
being overcome by the leverage of the long fragment of the 
shaft. The short arm of the lever (head or articular ex- 
tremity of the bone that becomes dislocated) is forced out- 
ward in a certain direction, gaining a purchase on the edge 
of the articular cavity, the capsule, a ligament, or a neigh- 
boring bony process, and its contact with the opposed 
articular surface is abolished. The capsule, after suffering 



GENERAL CONSIDERATIONS. 



79 



enormous distention, gives way and the head of the bone 
escapes through the laceration, assuming a definite position 
which is determined by the shape of the bone and of the 
surrounding soft parts, and by the action of the ligaments 
and muscles, — the dislocation is complete. 

A dislocation is always described in terms of the periph- 
eral part of the skeleton. Thus, for example, a dislocation 
of the shoulder-joint is 
spoken of as a luxation of 
the humerus. The direc- 
tion is also described ac- 
cording to that taken by the 
peripheral bone ; thus, for 
example, luxation of the 
humerus in front of the 
glenoid fossa when the head 
of the humerus lies in front 
of the articular cavity. 

The symptoms of a recent 
dislocation are, as a rule, 
very striking. The absence 
of the articular end of the 
bone from its normal posi- 
tion and its presence in an 
abnormal position produce 
a very distinct deformity 
which could be disguised 
only by a very great ex- 
travasation of blood. The 
position of the dislocated limb is almost always quite 
characteristic, and it is frequently possible to make the 
diagnosis by inspection alone ; besides, the position is, as a 
rule, typical in each form of luxation, because it depends 
on the action of certain portions of the capsule and liga- 
ments w T hich remain intact in regular forms of luxation. 
The dislocated limb persistently assumes its new position ; 
that is to say, while it may be forced to perform the normal 




Fig. 22. — Laceration in the cap- 
sule on the posterior aspect of the 
hip- joint. 



80 FRACTURES AND DISLOCATIONS. 

excursion (destroyed by the luxation) by means of external 
pressure and traction, it immediately returns to its ab- 
normal position as soon as the pressure is removed. The 
last-mentioned symptom is the most important one in the 
differential diagnosis between dislocation and fracture, as 
this tendency to return to the abnormal position is absent 
in fracture of a joint. There are other important symp- 
toms in dislocation, such as the absence of the normal 
prominence of the bone, the ability to feel the articular ex- 
tremity in an abnormal position, and the altered direction 
of the long axis of the bone. Mensuration is sometimes 
useful, as some dislocations are characterized by lengthen- 
ing instead of shortening of the affected extremity. 

As in fractures, so in dislocations, there may be ad- 
ditional injuries — injuries to nerves and blood-vessels, or 
extensive laceration of the soft parts surrounding the joint. 
Even the outer skin may be injured, lending to the injury 
the character of a compound dislocation ; in such cases the 
treatment must be carried out according to strict aseptic 
principles. 

[Compound dislocations without fracture are rare. The 
results, however, from proper treatment instituted early 
after the injury are excellent. The wound should be 
thoroughly irrigated with 1 : 1000 bichlorid, and loose 
pieces of tissue cut away. In many instances the capsule 
of the joint can be sutured and the wound closed without 
drainage. If later the joint becomes distended with 
effusion it should be aspirated. The introduction of gauze 
and drainage-tubes into the joint should be condemned. 
They irritate the synovial sac and increase the danger of 
subsequent ankylosis. If drainage is indicated, a small 
piece of rubber tissue answers the purpose best. In the 
majority of cases it is better, however, to close the joint 
capsule at once, and if indicated drain only the superficial 
wound. I believe that improper drainage in joint injuries 
is more frequently the cause of secondary infection and 
restricted motion than the injury itself. — Ed.] 



GEXEEAL CONSIDERATIONS. 81 

The diagnosis is sometimes very difficult when the dis- 
location is complicated by a fracture. This rare compli- 
cation is usually produced by the external force continuing 
to act after the luxation has been produced. 

The treatment has for its object the restoration or 
replacement of the dislocated bone (reduction). While it 
was formerly customary to employ great force in the reduc- 
tion of a dislocation, — a proceeding which was not infre- 
quently followed by grave consequences, such as the 
laceration of large vessels and nerves and the fracture of 
bones, — the general practice nowadays is to effect reduc- 
tion by manipulations based on a careful study of the 
anatomic relations and without the use of great force — 
generally under anesthesia. The rule that the reduction 
must be accomplished by forcing the dislocated extremity 
over the same path which it followed in the production of 
the dislocation is in the main correct. The manipulations 
should not be determined by thumb rule, but by accurate 
knowledge of the position of the articular head, of the tear 
in the capsule, and of the surrounding soft parts. u Our 
therapeutic actions nowadays are determined primarily by 
the anatomy of the dislocation " (Kronlein). 

Successful reduction is recognized by feeling the bone 
glide back into place, and observing that the normal out- 
line of the articular region and the normal mobility of the 
joint have been restored, while the tendency to return to the 
abnormal position has disappeared. 

With regard to the subsequent course, after reduction, 
the following points may be of some importance. Under 
normal conditions, if rest has been secured by appropriate 
dressings, the tear in the capsule heals, the extravasation 
of blood disappears, and the slight synovitis which is the 
expression of irritation in the joint subsides in from one to 
two weeks. As soon as possible, even before the end of 
this period, massage and careful passive movements can and 
ought to be instituted. If, as occasionally happens, pain 
and symptoms of articular irritation return, massage must 
6 



82 FRACTURES AND DISLOCATIONS. 

be discontinued or at least performed with great gen- 
tleness. After the third week the excursions are to be in 
creased and active exercises with the use of apparatus 
indicated. Eventually a complete restoration of function 
should be aimed at. 

[The after-treatment of a dislocation is quite as impor- 
tant as that of a fracture. It must be remembered that 
besides the tear in the capsule other important ligaments 
may be stretched or torn. The proper healing of these fi- 
brous structures takes a number of weeks, and during this 
time the joint, although it may be used to a certain extent, 
should have some form of support. If this is neglected, 
a permanent disability in the form of a weak joint or 
a tendency to recurrent dislocations from slight trauma 
may result. Hasevroek 1 has called attention to the ne- 
cessity of this longer support, and describes and illustrates 
a number of simple apparatus which not only give sup- 
port, but allow certain motions of the joint. — Ed.] 

The term habitual dislocation is used to designate the 
frequent recurrence of a dislocation, often under the influ- 
ence of quite inconsiderable force. The patients are per- 
fectly aware of their condition and usually have their 
diagnosis ready when they consult the physician ; not a 
few are able to reduce the dislocation themselves. The 
cause of habitual dislocation is usually to be sought in ex- 
tensive injury of the joint leaving an abnormally broad 
insertion of the capsule. For the treatment, such meas- 
ures as prolonged immobilization and the injection of alco- 
hol to produce shrinking of the tissues have been recom- 
mended. In very bad cases resection has been performed. 
It might be wise to try arthrotomy and partial extirpation 
of the capsule. 

[I do not believe that injections of alcohol or any other 
substance should be used. Prolonged fixation should be 
first given a trial with the form of apparatus recom- 

1 Munchener med. Wochenschrift, 1899, vol. xlvi, p. 93; reviewed 
in Progressive Medicine, December, 1900, p. 168. 






GENERAL CONSIDERATIONS. 83 

mended by Hasevroek, which allows some joint motion. 
If this fails, exploratory arthrotomy should be performed. 
In some eases the cause will be found to be quite simple, 
such as a loose cartilage, or a stretched or torn ligament. 
The cartilage should be removed and the ligament fixed 
by suture. Other cases will be more complicated. The 
condition, however, must be rare, because there is little in 
the literature on the subject, and even in a large surgical 
experience one observes these cases very infrequently. — 
Ed.] 

Under certain circumstances a dislocation may be irre- 
ducible. It may happen that, in spite of persistent 
efforts at reduction under anesthesia, it is found impossi- 
ble to put the bones in place. Failure may be due to the 
small size of the tear in the capsule, but, as a rule, it is due 
to the interposition of soft parts. If the edge of the ar- 
ticular surface was broken by the injury, it is evident that 
reduction may be impossible. In all such cases bloody 
reduction of the dislocation ought to be resorted to as early 
as possible. The joint must be opened as much as may be 
necessary to effect reduction. 

[In experienced hands, when reduction of a dislocation 
fails after the proper trial of the usual methods one should 
never hesitate to operate at once. Prolonged and forcible 
attempts at reduction are dangerous. With proper tech- 
nic the operation is a very simple matter, and seldom fails 
to reduce a recent dislocation. In the majority of in- 
stances one will find a sufficient cause which prevented the 
usual easy reduction of the dislocation; for example, a 
small fragment of bone, or an interposed tendon or muscle. 
—Ed.] 

If a dislocation is not reduced, there results the condi- 
tion known as an "old dislocation" complicated frequently 
by the formation of a new joint (a nearthrosis). Thera- 
peutic measures in such cases will be determined by the 
conditions found on careful examination. If the function 
of the new joint is satisfactory, as happens in very rare 



84 FRACTURES AND DISLOCATIONS. 

cases, no interference is indicated, and the surgeon should 
confine his efforts to enhancing the mobility of the new 
joint by means of passive exercises, etc.; but if the oppo- 
site is the case, there is nothing left but resection or 
arthrotomy, followed by the' replacement of the dislocated 
articular head in the original cavity. The latter should 
be the usual procedure, if for no other reason, because 
these cases of unreduced luxations are presenting them- 
selves for treatment earlier than they used to, and because 
the results obtained by replacement are, as a rule, much 
better than anything that can be hoped from resection. It 
is always more desirable, however, that reduction be 
effected as early as possible. 

[There is really no necessity for an old dislocation. In 
the recent state reduction is always possible. Nevertheless 
many cases come to the surgeon. The same rules should 
be followed in the reduction as those advised for recent 
dislocations : first, an attempt at reduction without opera- 
tion, always under anesthesia ; if this fails, an immediate 
operation, so that the patient is subjected to only one nar- 
cosis. In some cases of old dislocations resection gives 
much better results than reduction ; this is especially true 
at the shoulder and elboAV. The functional result of a 
proper excision of these joints is always excellent. On 
the other hand, in cases in which perfect reduction is pos- 
sible, the joint changes from the old injury are so advanced 
that marked restriction of motion is always present, and 
the function of the arm is never as good as after a resec- 
tion. Experience and the study of the soft parts around 
the joint will usually indicate the better procedure. — Ed.] 



II. FRACTURES OF THE SKULL 

In the study of fractures of the skull it is of interest to 
know that the doctrine of a certain elasticity of the skull 
promulgated by Bruns has been confirmed by recent inves- 



FRACTURES OF THE SKULL. 



85 



titrations carried out with the best instruments and under 
the observance of all necessary precautions. The skull, 
in fact, possesses a certain elasticity ; and a force acting 
on it from without must overcome the limit of its elasticity 
before producing a fracture. This is equally true of frac- 
tures of the base of the skull. 



(A) FRACTURES OF THE SKULLCAP 

In fractures of the vault of the cranium it is noticeable 
that the inner table suffers more extensively and exhibits 





Fig. 23. — A B represents the segment of a skull, a b showing the 
points of impact of an external force. The first effect of the force is 
to produce a certain flattening of the skull, as at A f B / ; at the same 
time the point of impact at a b is compressed and the corresponding 
portions of the internal table are stretched, the particles of bone being 
pulled apart to the point of bursting. This is readily understood by 
comparing the quadrilateral abed in the two figures. (After Teevan. ) 

greater dislocation of its fragments than the outer table. 
This phenomenon was formerly explained by assuming a 
greater brittleness for the inner table, which was accord- 
ingly named tabula vitrea. In recent times it has been 
found that the phenomenon depends on certain simple 
mechanical laws, and that in any injury of the vault that 
table which is furthest removed from the injuring force 
suffers the most extensive fracture. A glance at the illus- 
tration on Plate 9 suffices to show the important fact that 
an injury of the vault of the cranium from within — that 
is, from the cavity of the skull — produces the same appear- 



86 FRACTURES AND DISLOCATIONS. 

PLATE 9. 

Fractures of the Vault. — Fig. 1. — Gunshot wound from with- 
out and from within. Fragment of the skullcap of a cadaver showing 
the marks of two bullets fired with a small charge of powder, one 
bullet striking from without, the other from within. The direction 
of the bullets is indicated by arrows. The section shows that the 
point of entrance represents a round hole, while the point of exit is 
marked by a larger and more irregular loss of substance. (Author's 
collection. ) 

Fig. 2. — Effect of a projectile with low velocity discharged from 
without (artificial). The force was not sufficient to perforate the 
skull ; the point of impact on the skull is marked only by a slight de- 
pression, while the internal table shows extensive shattering of the 
bone. (Author's collection.) 

Figs. 3 a, 6, c. — Old fracture of the skullcap with depression of the 
fragments. Firm union of the bone had taken place with some thick- 
ening at the seat of fracture. Figure 3 a shows the preparation from 
within ; figure 3 b, from without ; figure 3 c, in transverse section. 
In this preparation also the splintering of the internal table is more 
extensive than that of the external. (From the collection of the Path. 
Anat. Institute at Greifswald.) 

ance of more extensive shattering on the outer table as is 
usually seen on the inner table under ordinary circum- 
stances, when the injuring force is applied to the skullcap 
from without. According to Teevan, it appears that the 
effect of a force acting from without, such as a spent ball, 
a small stone, or a stick, is to induce a certain bending of 
the skullcap at the point of impact. This bending process, 
as long as it is confined within the limits of elasticity, pro- 
duces only a slight flattening of the normal curve of the 
bone. The particles of bone in the external table are com- 
pressed, while those in the internal table are distended ; 
i. e., forced apart. Just as when a stick is broken over 
the knee the fracture begins on the convex side, — that is, 
the side on which distention and separation of the particles 
take place, — so in the same way the fracture begins and 
becomes most extensive on the distended side of the skull 



Tab. 9. 




£fy*. 





Fig. 3 b 



Fig,3c 




Litfi.Anst 



FRACTUBES OF THE SKULL. 



87 



which is furthest removed from the injuring force. This 
explanation is confirmed by numerous preparations as well 
as by experiments, and is now generally accepted. 1 

The correctness of this theoretic view is proved by a 
few preparations obtained from the skulls of suicides who 
ended their lives by shooting themselves through the 
mouth. In these cases the fracture of the so-called vit- 
reous table is slight, while that of the external table is 
<mite extensive. 





Fig. 24. — Bullet mark in a fragment of the skullcap of a male 
cadaver; the bullet struck the inner table of the skull. The point 
of entrance on the inner table is marked by a round hole, while the 
point of exit in the external table shows a more extensive loss of sub- 
stance. The fragment when removed presents the form of a mush- 
room seen from the side; seen from above or without, it has a pecu- 
liar rosette-like appearance, being composed of several pieces loosely 
held together. The author has observed this condition repeatedly. 



We can, therefore, readily understand that under cer- 
tain conditions — that is, when the force is slight — a blow 
delivered with a blunt instrument on the outside of the 
skull may produce an isolated fissure of the internal table, 
unmistakable cases of which have been observed (see 
Plate 9, Fig. 2). In such a case the effect of the injuring 
force must have ceased to act as soon as the continuity of 

1 Bony tissue offers greater resistance to a rending than to a com- 
pressing force (Rauber). 



88 FRACTURES AND DISLOCATIONS. 

PLATE 10. 

Gunshot Wound of the Skull.— Figs. 1 and 2 show the ante- 
rior and posterior sides of a skull which was struck at a distance of 200 
meters with the projectile of a German infantry rifle (model 88) ; a 
full charge of powder was used. 

The illustration shows the small round hole at the point of entrance 
and the large ragged hole at the point of exit. It was impossible to 
replace the mass of minute fragments at the point of exit. The skull 
was broken into a number of variously sized pieces separated by num- 
erous approximately radiating lines of fracture, and grouped more or 
less concentrically about the points of exit and entrance. The frag- 
ments were carefully united with wire. 

the bone was destroyed on the distended side, before the 
compressed particles of bone on the other side became 
separated. In the same way the opposite condition may 
occur in exceptional cases ; that is, an isolated fissure of 
the external table may be produced by a force acting from 
within, when, for example, the force of the bullet was not 
great enough to perforate the skullcap. This condition 
has also been observed in preparations. Under certain 
circumstances — for instance, when the direction is oblique 
— a force acting from without may injure the outer table, 
while the inner table remains intact. While this condi- 
tion is rare as the result of a blow with a blunt instru- 
ment, it is frequently observed in sabre wounds. 

Somewhat more frequent than isolated fractures of the 
inner table are those cases in which the outer table pre- 
sents only a slight injury, as a depression or a fissure, 
while the inner table is completely shattered, the splinters 
being forced into the cavity of the skull like the rafters 
of a roof. Then there are the severe forms of fracture of 
the skull (piece fractures) in which an extensive area of 
the cranium suifers complete fracture with depression of 
the splinters which are attached around the margin of the 
fracture at the normal level. In this variety also the 
destruction and displacement of fragments is more exten- 
sive on the inner table (compare Plate 9, Fig. 3). 




' v V 



JL'-V 






Iz* 




FRACTURES OF THE SKULL. 89 

For the sake of completeness it should be mentioned 
that a solution of continuity in the vault of the cranium 
may coincide with a suture (diastasis), and from such 
fractures radiating fissures often extend to some distance 
(Plate 13, Fig. 1 ; Plate 11, Fig. 1 b). 

Gunshot wounds of the skull at short range as a rule 
produce a general shattering, which is explained, accord- 
ing to the most recent views, as the result of hydro- 
dynamic pressure transmitted by the cerebral mass. 

In examining severe compound fractures of the vault 
of the skull it is always to be remembered that the frag- 
mentation of the bone is much more extensive on the 
inner table than on the surface. In the treatment of 
these compound fractures of the skull the most careful 
cleansing of the external soft parts, which are frequently 
very much polluted, should be the surgeon's first care. 
This is best accomplished by removing the contused and 
polluted masses of tissue with a knife and scissors. The 
next step should be to raise the depressed fragments; 
this requires trephining at the margin of the fracture (or, 
better, chiseling). In most cases complete asepsis can- 
not be attained without removing all the splinters of 
bone and exposing the dura, which shows the typical 
cerebral pulsations. For the rest, the treatment of the 
wound should follow general surgical rules. The loss 
of substance may at some later time be repaired by an 
osteoplastic operation, either by taking a plate of bone 
from the immediate surroundings or in some other similar 
way. 

The reason for this radical procedure and the removal of 
all splinters of bone is the possibility, or rather probability, 
that polluted particles of matter from the outside have be- 
come lodged between the fragments of the fracture. In 
specimens showing fracture of the skull hairs are often 
found wedged in between the fragments. This I have re- 
peatedly observed in macerated specimens from the Path- 
ologic Institute at Leipzig and the one at Mimchen. The 



90 FRACTURES AND DISLOCATIONS. 

obvious explanation is that there is a greater interval be- 
tween the fragments at the time the fracture is produced 
than later, and during the instant when their separation is 
greatest hair may be forced into the wound by the external 
violence. "When the edges of the fracture come together after 
the force has ceased to act, the hairs may become so firmly 
caught between them that they even resist maceration of 
the bones. Hence we can readily understand that infective 
material, possibly along with hair, may equally well be 
carried from without into the depths of the wound, and, if 
the wound is not sufficiently opened, may lead to meningitis. 

In recent subcutaneous fractures operative interference, 
such as trephining, is much more rarely indicated. Our 
former views on this question have been revised, and we 
now know that moderate grades of compression are not 
necessarily followed by grave consequences to the brain. 
A slight diminution of the capacity of the skull is of no 
particular significance. It is true that disturbances may 
manifest themselves later on in such cases, so-called Jack- 
sonian epilepsy, for example, and may call for operative 
interference. 

[The operative procedure for a fracture of the skull (the 
vault) is so simple and so free from danger that surgeons, 
in this country at least, believe that no exception should be 
made in a depressed fracture, or in any fracture of the 
vault in which there is a possibility of depression. To 
elevate such fractures it is seldom, if ever, necessary to use 
the trephine. The elevated or overriding edge should be 
chiseled until the edge of the depressed fragment is free ; 
now it can be easily lifted in place. In the procedure one 
should remove as little bone as possible. — Ed.] 



(B) FRACTURES OF THE BASE OF THE SKULL 

It is readily seen that fractures of the base of the skull 
are chiefly produced by indirect violence. Direct injury 
of the base of the skull is possible only by way of the 



FRACTURES OF THE SKULL. 91 

orbital or nasal cavity, and such injuries are exceedingly 
rare. A bullet may, of course, strike the base of the skull 
from any direction. The occurrence of fracture of the 
base was formerly explained by the idea of contrecoup or 
counterstroke. By this was meant that the mechanical 
effect of an external force applied to the roof of the skull 
was to produce a certain wave-like movement in the ad- 
jacent portions of the bone, and that the vibrations thus 
produced became collected on the side opposite to that 
which was exposed to the injuring force by a process of 
summation, and thus produced a fracture of that side — so- 
called fracture by counterstroke. With the increase in 
surgical knowledge the doctrine of contrecoup has lost 
much of its importance. A large proportion of the forms 
of fracture of the base about to be described were for- 
merly described by this doctrine of counterstroke. A 
force acting at more than one point (double-acting force) 
may simulate so-called fracture by counterstroke ; as, for 
instance, a blow on the forehead followed by a fall on the 
occiput, where the autopsy may show, in addition to a 
fracture in the frontal, a second one in the occipital bone. 
Nowadays the doctrine of contrecoup in the sense just 
given is hardly tenable. 

Careful examination of fractures of the base at the 
autopsy and numerous experiments demonstrate that many 
indirect fractures of the base present a certain regularity 
of form and permit a definite explanation. This, of course, 
applies only to fractures produced by a moderate degree of 
force ; when the force has been great enough to produce 
general destruction, there is no regularity whatever in the 
lines of fracture. 

The following points are of importance in explaining 
the shape and direction of fractures of the base : 

1. The base of the skull is regarded as the weakest por- 
tion of the skull This statement is only partially true ; 
for connecting the thinner and partly translucent portions 
— which, in addition, are perforated by large openings for 



92 FRACTURES AND DISLOCATIONS. 

PLATE 11. 

Fracture of the Skullcap Continued to the Base.— The pa- 
tient was struck in the parietal and temporal region by a falling roof- 
tile and sustained a compound fracture with depression of the frag- 
ments and a wide crack in the bone, followed by extradural hemor- 
rhage from the middle meningeal artery. The patient recovered. 

By combining this case with a specimen in the collection of the 
Path.-Anat. Institute at Greifswald, the figures on Plate 11 were 
obtained. 

Fig. 1 a shows the skull with the calvarium removed, and the brain 
within the uninjured dura. A large hemorrhage from the middle 
meningeal artery, two branches of which are visible, is seen at the 
typical site. The crack in the bone extends down to the base of the 
skull. 

Fig. 1 b shows the calvarium. The fracture in part follows the 
suture, and ends as a fissure in the parietal bone. 

Fig. 1 c. — Base of the skull belonging to the specimen; seen from 
within. The fracture traverses the middle fossa of the skull. 

the passage of nerves and vessels — are firmer and in part 
extremely robust sections of bone which act as a kind of 
buttress. Thus a lateral support is supplied by the petrous 
portion of the temporal bone and the junction of the edges 
of the wings of the sphenoid ; behind the skull is braced 
by the occipital crest, and in front by the frontal crest. 
These structures converge toward the clivus and the ante- 
rior margin of the foramen magnum. It has been learned 
by observation that fractures of the skull preferably follow 
the intervals between these supporting buttresses (Felizet). 
It is not to be denied, however, that the petrous portion 
of the temporal bone is often involved. 

2. By far the greater portion of fractures of the base have 
their beginnings in severe fractures of the vault. Such are 
the so-called " continued fractures " {fractures par irra- 
diation). They begin on the convexity of the skull, at 
the point of impact of the injuring force, and in many 
cases follow the shortest route from that point to the base of 
the skull (Aran's law). If the position of the buttresses 



Tab. II. 




Fig.lff 



% t 





Fig A > 



Lith.Arist E Reichholil Miimhe 



FBACTUEES OF THE SKULL. 93 

mentioned in (1) is borne in mind, an explanation is at 
once obtained for these fractures of the base that traverse 
the anterior fossa of the skull and take their origin in an 
injury to the forehead ; for those that pass from the parietal 
or temporal region to the middle fossa of the skull between 
the wings of the sphenoid and the petrous portion of the 
temporal ; or for those that follow a fall on the occiput 
and occur between the petrous portion of the temporal 
bone and the occipital crest. This is the mechanism in 
about 40 f of fractures of the base belonging to this class. 
In the majority of such fractures the force of the blow is 
such as to produce irregular lines of fracture and often an 
injury of the buttresses themselves. The middle fossa of 
the skull contributes by far the greatest number of frac- 
tures of the skull. They are usually transverse ; frequently 
the line of fracture unites the middle fossa* of the skull ; 
more rarely they follow an oblique course into the anterior 
fossa of the other side. 

3. Another class of fractures of the base are produced 
by indirect violence, parts of the facial bones or the verte- 
bral column being actually driven into the base of the 
skull. If an individual should fall on his head without 
suffering direct injury to the roof of the skull, the weight 
of the after-coming vertebral column might nevertheless 
produce pressure on the base of the skull in the vicinity 
of the foramen magnum after the head has struck the 
ground. In such a case the skull would be crushed as by 
a direct force. The same thing is possible if the trunk or 
the legs are the first to strike the ground and the skull, so 
to speak, presses itself against the vertebral column, the 
direction of which is perpendicular to the base of the skull. 
These fractures present very characteristic appearances 
(Plate 12), and can also be produced experimentally. 

A fracture of the base may also result from a force 
transmitted by the bones of the face in a manner similar 
to that produced by the vertebral column, but such acci- 
dents are much less frequent. Plate 13 shows a specimen 



94 FRACTURES AND DISLOCATIONS. 

PLATE 12. 
Various Fractures of the Vault and Base of the Skull.— 

Fig. 1. — Vault of the skull with a fissure in the left parietal bone and 
separation (diastasis) of the right half of the lambdoid suture. The 
fissure is directly continuous with the sej)a ration of the suture. (Path.- 
Anat. Institute, Greifswald.) 

Fig. 2. — Fracture of the base of the skull by pressure of the after- 
coming vertebral column in a fall on the head. The bones about the 
foramen magnum are fractured and in the macerated specimen have 
partly come away. (Author's observation; also artificial, and after 
Baum, Arch, fur klin. Chir., vol. xix, p. 381.) 

Fig. 3. — Sagittal section of the base of the skull at the articulation 
of the left lower jaw. The picture shows the relations about the articu- 
lations of the jaw, and especially the extreme thinness of the skull 
bone at this point. 

in which a blow in the region of the nose forced the bony 
portion of the nose into the anterior fossa of the skull and 
brought about a most characteristic displacement of the 
crista galli. Plate 12 represents the base of the skull in 
sagittal section through the articulation of the jaw, and 
serves to remind us that this is the thinnest portion of the 
base of the skull, which at this point is often translucent. 
A force applied to the lower jaw, if transmitted to the 
ascending ramus, and especially to the articular processes 
(fall on the chin while the mouth is open), may produce 
fracture of the base of the skull. An actual forcing 
through of the articular process into the cranial cavity 
through a wide crack at this point has even been described. 
Accidents of this kind are extremely rare, however, because 
the lower jaw itself in this mechanism usually becomes 
fractured and because the thin spot is protected by robust 
bony margins in its immediate vicinity. 

4. In extremely rare cases a fracture of the base may be 
produced by compression of the skull as a whole. Such an 
effect would have to overcome the natural elasticity of the 
skull ; but if the compressing force is prolonged, a frac- 
ture will be produced. It has been shown experimentally 




Tab. 12. 




Eiff.2. 







SSfc « 









/ 






Fig.3. 



Lilh. Anst F. Reich ho Id Miinchen . 



FRACTURES OF THE SKULL. 95 

that these fractures followed the long axis of the skull 
when the compression took place in the long axis, and 
traversed the base of the skull transversely when the 
compression took place in a transverse direction. The 
lines of fracture are, of course, not the same in every 
instance, but in a general way they present the same char- 
acter (compare Plate 14). A transverse fracture may 
traverse either the middle fossa of the skull or the petrous 
portion of the temporal bone. 

This disposes of all but the rare isolated fractures, espe- 
cially of the orbit, and fissured fractures of the base in 
gunshot injuries. In the production of the latter the 
action of hydrostatic pressure, with the consequent effect 
of a vacuum, is now conceded to play the most important 
part. It need not be a matter for astonishment that in 
such injuries, which affect the skull as a whole, the weak- 
est portion should present the fracture or fissure. Further 
theoretic discussions of these questions will be found in the 
larger text-books devoted to the subject. 

The symptoms of fracture of the base vary greatly 
according to the seat of the fracture and the fossa of the 
skull involved. The following symptoms are most impor- 
tant for the diagnosis : 

1. Hemorrhage. — This may take the form of a suggil- 
lation under the skin. It is, however, of importance only 
when it appears at some distance from the point of injury. 
Extravasation of blood in the region of the eyes is more or 
less significant of fracture of the anterior fossa. There is 
no doubt that nearly all fractures of the orbital roof pre- 
sent hemorrhage into the orbital fat, and as the hemorrhage 
becomes more and more extensive it gradually leads to 
suffusion of the bulbar conjunctiva, and finally of the lids. 
Exophthalmos does not occur unless the collection of blood 
is very great ; it is of importance only when the frontal 
region is absolutely uninjured. Suggillation in the pharyn- 
geal mucous membrane is rarely observed. Hemorrhage 
from the nose is more frequent. When the patient is in 



96 FRACTURES AND DISLOCATIONS. 

PLATE 13. 

Fracture of the Base of the Skull by an Injury to the Nasal 
Region. — Figs. 1 and 2. — Section and anterior view of a skull in 
which fracture of the base was produced by a compression-injury to 
the nasal and superior maxillary region. 

The specimen was prepared from the cadaver of a man twenty-eight 
years of age who had been admitted to the Leipziger Krankenhaus 
with the diagnosis of fracture of the nose, and died of meningitis on 
the 12th of April, 1876. At the autopsy there was found this remark- 
able condition, which was immediately photographed. 

The section shows the dislocation of the nasal and ethmoid bones, 
which was in the main upward, so that the crista galli was thrust into 
the interior of the cranial cavity. The anterior view also shows the 
dislocation of the nasal bones and numerous lines of fracture at the 
orbital margin on both sides. (Author's observation. ) 

[Meningitis is not an uncommon complication of fractures of the 
nose associated with fracture of the base of the skull communicating 
with the nasal cavity. The complication is fatal. I do not believe 
it can be prevented by an attempt to disinfect the nasal cavity. 
In fact, I think it is better to let the nose alone and not disturb the 
blood-clot. Perhaps future experience will teach us that an operation 
should be performed the moment the symptoms of meningitis begin. 
The base of the skull should be exposed through an opening in the 
frontal bone and drainage instituted. I have observed one case in 
which this procedure at least should have been attempted.— Ed.] 



the dorsal position, or if the posterior portion of the nose 
has been injured, the blood may flow doAvn into the pharynx 
and be swallowed, and later give rise to hematemesis. In 
fractures involving the middle fossa of the skull and of 
the petrous portion of the temporal bone hemorrhages from 
the ear (external meatus) are frequently observed. In the 
differential diagnosis it is necessary to exclude the entrance 
of blood into the auditory canal from without • simple rup- 
ture of the drumhead ; fracture of the anterior wall through 
the articular prominence of the lower jaw in a fall on the 
chin ; and fracture of the posterior wall and of the mastoid 
process. For the production of hemorrhage from the ear 



Tab. 13. 




\ ^ 






Fig.l. 




Fig.£. 



LitfuAnst.EReU 



FRACTURES OF THE SKULL. 97 

it is obvious that the fracture of the base must be compli- 
cated by laceration of the drumhead. Suggillation at the 
mastoid process developing several days after the accident 
appears to possess some diagnostic significance pointing to 
fracture of the posterior fossa of the skull. 

2. Escape of brain=matter is a rare occurrence, observed 
only in the most severe forms of fracture. It is a positive 
sign of fracture of the base, with accompanying concus- 
sion of the brain and laceration of the meninges. Escape 
of brain-matter into the ear and into the external auditory 
meatus is relatively the most frequent form of the accident. 
Escape of cerebrospinal fluid, on the other hand, is much 
more frequent. It is observed after the hemorrhage from 
the ear has ceased, sometimes twenty-four hours after the 
injury. The amount of serous fluid discharged is usually 
quite considerable ; the drops follow each other in rapid 
succession and can be collected in a test-tube. The fluid 
is clear unless mixed with blood, of alkaline reaction, and 
shows only a trace of turbidity on boiling ; it is, therefore, 
free from albumin, but contains a little sugar and an abun- 
dance of sodium chlorid. Escape of a serous fluid of this 
character is a positive sign of fracture of the base with 
laceration of the meninges, but the symptom is much less 
frequent than hemorrhage from the ear. 

3. Injury to the Nerves at the Base of the Brain. — 
If this symptom makes its appearance at once or very 
soon after the injury, it is a sign of laceration or contusion 
of the nerves within their bony canals, which have there- 
fore been included in the line of fracture. If a paralysis 
in the distribution of one or more of the cranial nerves 
occurs late in the course of the disease, it is to be referred 
to an inflammatory process extending from without inward, 
which may end in fatal basilar meningitis. The cranial 
nerves that most frequently suffer primary injury in frac- 
tures of the base are the facial and auditory. This is 
explained by the greater frequency of fractures in the 
middle fossa of the skull and the course of these nerves in 

7 



98 FRACTURES AND DISLOCATIONS, 

PLATE 14. 
Fractures of the Base by Compression of the Skull.— 

Fig. 1. — Transverse fracture of the base artificially produced by 
transverse compression of an unopened and uninjured skull from a 
recent cadaver. 

Fig. 2. — Fracture of the base due to compression of the skull in its 
long axis from sinciput to occiput. The patient, a man thirty-five 
years old, was injured by a fall on the head from a height of 10 feet. 
At the autopsy it was found that the fracture had traversed the fora- 
men magnum. l Similar appearances are observed in artificially pro- 
duced simple compression fractures. 

the petrous portion of the temporal bone. The other nerves 
are much less frequently involved. 

In 48 fractures of the base Kohler observed 22 cases of 
facial paralysis, and only 2 of paralysis of the abducens. 
Battle, in an analysis of 168 fractures of the base, reports 
2 cases of laceration of the olfactory nerves, a very few 
cases of paralysis of the oculomotor, 5 palsies of the ab- 
ducens, 15 facial palsies, 14 cases of isolated deafness, and 
8 cases of blindness due to hemorrhage into the sheath 
of the optic nerve; the latter was confirmed by autopsy. 

Clinical Course and Prognosis of Fractures of the 
Base. — It was formerly held that a fracture of the base 
was necessarily a fatal injury. We now know, however, 
from clinical and postmortem observation, that recovery is 
possible after fracture of the base unless the force has been 
so great as to produce lesions of the brain and of the large 
nerve-trunks, or a fatal hematoma within the cranium. 

Cerebral symptoms are rarely absent in cases of frac- 
ture of the base. The mildest injury with which we have 
to deal in this connection is concussion (commotio cerebri), 
a condition characterized by unconsciousness [not always] , 
vomiting, disturbance of cardiac action, and, usually, re- 
tardation of the pulse [brachycardia] . The symptoms 

1 Hutchinson, Illustrations of Clinical Surgery, vol. I, Plate 30. 



Tab.l*. 




FigJi. 




Ikj.l. 



Liih. Anst E Reichhold, Munch e 



FRACTURES OF THE SKULL, 99 

are transient; if the loss of consciousness lasts longer 
than a few hours, or at most from twenty-four to thirty-six 
hours, a severe injury of the skull should be suspected. 
In some cases the patient loses all recollection of the occur- 
rence. As a rule, the symptoms disappear completely and 
recovery results. 

Simple cases of concussion are less frequent than was 
formerly supposed. The theory of an agitation of the 
cerebral mass by an oscillating motion, which was formerly 
held, is hardly to be accepted, as it seems probable that in 
any violent injury to the skull there is always a displace- 
ment of the brain as a whole. If the force has been suffi- 
cient to crack the skull, contusion of the brain=matter 
(contusio cerebri) may be assumed to be present at the seat 
of the injury, and not infrequently a similar contusion 
of the opposite side is produced by the dislocation of 
the brain just referred to. This occurs particularly in 
fractures of the occiput. The contused area presents grave 
anatomic alterations, hemorrhages into the brain, and, not 
infrequently, laceration of the brain-substance. The ner- 
vous symptoms are due to loss of certain brain-centers, 
and their character accordingly depends on the part of the 
cortex affected. In addition to general, we then also have 
focal, symptoms. Marked elevations of temperature have 
recently been observed in cases of contusion of the brain 
and intradural hemorrhage at the base of the frontal and 
temporal lobes, meningitis being excluded by the autopsy. 

Under certain conditions a compression of the brain 
(compressio cerebri) may result. It is established, both by 
clinical observations and by experiments, that a relatively 
large diminution of the cranial cavity must take place be- 
fore the phenomena of compression are produced. Small 
extravasations and depressed fractures, unless they are of 
unusual extent, do not produce the symptoms of compres- 
sion. This is .probably to be explained by escape of 
cerebrospinal fluid. Pressure symptoms are produced in 
fracture of the skull principally by injury to the middle 

L.efC. 



100 FRACTURES AND DISLOCATIONS. 

PLATE 15. 

Fracture of the Skull with Laceration of the Middle 
Meningeal Artery, the Line of Fracture Extending to the 
Base of the Skull. 

Fig. 1. — Hemisection of a skull, on the inner surface of which' the 
direction and extent of a fracture, observed by the author, have been 
outlined. The details were obtained by actual measuring, and the 
drawing was at the autopsy. The case was that of a laborer twenty 
years of age who had fallen from the fourth story of a building. On 
admission to the clinic an extravasation was found in the region of 
the left temple ; fracture of the left squama was detected by palpation. 
There followed hemorrhage ; later, discharge of cerebrospinal fluid 
from the left ear ; and paresis of the left half of the face and of the 
extremities on the right side of the body. The patient died of 
tetanus contracted through a contused wound in the region of the 
trochanter. The illustration shows the seat of the hemorrhage in 
the distribution of the posterior branch of the middle meningeal 
artery. It also shows the ramifications of the artery, the line of frac- 
ture, and the suture between the left parietal and frontal bones. 
(Author's observation.) 

Fig. 2. — Horizontal section through the skull and its contents. A 
copious hemorrhage from the middle meningeal artery is found at the 
seat of fracture between the skull and the dura. The brain is com- 
pressed and displaced. (After Hutchinson, Illustrations of Clinical 
Surgery, vol. II, Plate 54. ) 



meningeal artery and consequent hemorrhage between the 
dura mater and surface of the bone which lessens the con- 
vexity of the brain (see Plate 9). In typical cases of this 
kind the initial symptoms of concussion soon disappear, 
the patient regains consciousness, and appears to be on the 
road to recovery; soon, however, the symptoms reappear, 
first irritation and later paralysis and mental depression, 
ending in loss of consciousness, retardation of the pulse, 
and finally profound coma. In such a case the only hope 
lies in trephining the skull over the hemorrhage, turning 
out the blood-clot, and, if necessary, ligating the middle 
meningeal artery. 



Tab. 15. 




Tig.l. 







Fig. 2. 



l.ith.Atist K HeichhoUl. Mimchen . 



FRACTURES OF THE SKULL. 101 

It appears, therefore, that fracture of the base, even 
excluding rare complications, presents many dangers ; the 
mortality is great, and depends of course on the severity 
of the injury and the presence or absence of complications. 
Fractures through the middle fossa of the skull are by 
far the most frequent, but fractures through the posterior 
fossa have the greatest mortality. 

The treatment of uncomplicated fractures of the skull 
is in the main expectant : rest, good nursing, if necessary 
esophageal feeding, and the local application of cold. 
Great care must be exercised to guard the patient against 
any additional injury. 

It is an open question whether the external auditory 
meatus should be cleansed with a disinfecting solution when 
there is hemorrhage from the ear. Personally I consider it 
impossible to achieve complete disinfection in this way, and 
only allow the outer portion of the meatus to be carefully 
wiped out. On the other hand, the ear itself and the sur- 
rounding skin are thoroughly disinfected and dressed with 
sterile cotton. The objection to using a syringe is that 
there is danger of carrying infection to the deeper portion 
of the wound and thus bringing on meningitis. 

As the pressure of the hemorrhage on the surface of 
the brain rather than the contusion of the brain-substance 
is regarded as the cause of death, it follows logically that 
trephining is greatly to be recommended. Some very 
satisfactory results have been obtained by this operation in 
recent times. 

Fractures of the skull heal by bony union with an aston- 
ishingly small amount of callus-formation, which is owing 
to the slight degree of dislocation, to the fact that the frag- 
ments are completely put at rest, and to the fact that the 
capacity of the dura mater for producing bone is less than 
that of the periosteum of the long bones. In rare cases 
loss of substance remains after fracture of the roof of the 
skull, especially in small children ; it is sometimes accom- 
panied by meningocele. 



102 



FRACTURES AND DISLOCATIONS. 



III. INJURIES OF THE FACIAL BONES 

The bones of the face are accessible to examination 
either from without or by way of the nasal and aural cavi- 
ties, so that fracture of these bones rarely presents diag- 
nostic difficulties. Fractures of the nasal bones are always 

to be regarded as 
j^ compound, since 

there is necessarily 
an open communica- 
tion between the seat 
of fracture and the 
nasal or oral cavity. 
It is remarkable that 
notwithstanding this 
condition recovery 
usually takes place 
without any special 
complications or 
dangers due to in- 
fection. Injuries of 
the nasal bones are 
always due to direct 
violence by a blow or 
a fall. Fracture of 
the nasal bones and 
parts of the bony 
septum behind them 
usually produces dis- 
tinct, and sometimes 
excessive, deformity 
(traumatic saddle-nose) ; the displacement may be reduced 
in recent cases by means of a forceps introduced through the 
nasal cavity. The obvious symptoms are suggillation, and 
hemorrhage from the nose ; a slight degree of cutaneous 
emphysema may be produced by entrance of air-bubbles 




Fig. 25. — Showing the action of the 

muscles in displacing the fragments in 
fracture of the lower jaw. 



INJURIES OF THE FACIAL BONES. 



103 



through the opening in the mucous membrane into the cel- 
lular tissue about the seat of fracture. [This is rare. — Ed.] 

Fractures of the malar and superior maxillary 
bones result from direct injuries, mostly the kick of a 
horse ; they are, therefore, very frequently compound. 
The diagnosis presents no* difficulties. The treatment de- 
mands reduction and fixation of the displaced fragments. 
This should be done by proper operation. This part of 
the treatment should be properly intrusted to a dentist, 
who may be able to save 
some of the teeth that 
have become loosened. I 
have sometimes obtained a 
good result by simply se- 
curing a fragment with a 
nail. The mouth must be 
kept clean with a 3 % 
boric acid solution, and the 
patient put on liquid diet. 

Fracture of the lower 
jaw is a more frequent 
accident. The condition 
is easily recognized, either 
from without or through 
the mouth, so very little 
needs to be said about the 
diagnosis. In fractures of the body or arch of the lower 
jaw a typical dislocation is observed, the posterior frag- 
ment being drawn upward by the masseter, while the an- 
terior fragment is displaced downward by the action of the 
digastric and other muscles attached to the chin. 

In the great majority of cases there is also a certain 
lateral dislocation by virtue of which the two fragments 
override each other so that the arch of the bone becomes 
shorter and narrower. Double fracture of the lower jaw 
is occasionally met with, and comminuted fractures are 
not so very rare. 




Fig. 26. — Specimen of fracture 
of the lower jaw with lateral dis- 
placement. 



104 FRACTURES AND DISLOCATIONS. 

PLATE 16. 

Fractures of the Lower Jaw.— Fig. 1.— Recent fracture of the 
body of the lower jaw. The line of fracture is oblique and corre- 
sponds with the region of the molar teeth which have disappeared. 
(Path.-Anat. Institute, Munich.) 

Fig. 2. — Interesting oblique fracture of the body of the lower jaw, 
involving both articular processes ; recent. The preparation is evi- 
dently the product of a very severe injury, probably a fall on the chin 
(see Fig. 3, Plate 12, including the description). (Pathol. -Anat. In- 
stitute, Munich.) 

Figs. 3 a and 3 b. — Fracture of the articular process of the lower 
jaw. The outer view (Fig. 3 a), and even more so the inner view 
(Fig. 3 6), shows the fragment which was diplaced downward and 
firmly held in that position. On the injured side the coronoid process 
projects beyond the upper extremity of the condyloid process ; the semi- 
lunar fossa is partly filled by the dislocated fragment. (Path.-Anat. 
Institute, Munich.) 

Fig. 4 a and 4 b. — Hammond's wire splint for fracture of the lower 
jaw. Figure 4 a shows it in position on the jaw. (After Rose, Ueber 
Kieferbiiche and Kief erverbande. ) 

Fracture of the lower jaw is almost always produced 
by direct violence, such as a blow, the kick of a horse, 
or a gunshot wound from without or through the oral 
cavity in suicidal attempts. Indirect fractures may, how- 
ever, be met with after a fall on the chin or lateral com- 
pression of the bone. Fracture of the alveolar process 
and complete separation of a fragment are relatively fre- 
quent accidents following unskilful or violent extraction 
of the teeth, especially with the forceps. 

With respect to the treatment, it must be remembered 
that fractures of the body of the lower jaw are always 
accompanied by a wound of the gums. They are, there- 
fore, to be regarded as compound fractures even when there 
is no injury to the skin. For this reason the oral cavity 
must be kept scrupulously clean by brushing the teeth and 
using a disinfecting mouth-wash, especially after eating. 
If the gum wound is extensive, it may be dressed with 



Tab. 16. 




Ficf.o h 




Fiq.J < 




Ekf.2. 



Fig. 4 b 






m 





rig 



r ml 1 . 




Fig. 4 a 



LUh.Anst E Reichhold, 



INJURIES OF THE FACIAL BONFS. 105 

iodoform gauze, which may, if necessary, be secured in 
place with sutures. [Pure carbolic acid is one of the best 
disinfectants to use in wounds about the gums and jaw. 
It should be applied with a cotton swab and followed at 
once with alcohol. — Ed.] 

Displaced fragments can, as a rule, be readily reduced 
by direct pressure, but permanent retention often presents 
considerable difficulties on account of the action of the 
muscles. Fortunately, we now have other means besides 
splints and other apparatus applied to the outside of the 
jaw and chin, and held in place by a roller bandage. 
AVith the help of a dentist, fixation of the fragments may 
be achieved by means of splints secured to the teeth of 
both fragments. Sometimes the simple procedure of tying 
together the teeth by means of silver wire wrapped around 
the crown suffices. It is only in cases where the teeth are 
lost, or under unusual conditions, that we are forced to 
resort to the older methods or to the use of a bone suture ; 
for the latter, thick silver wire is used, the necessary holes 
being first made with a drill. If the holes are correctly 
placed, dislocation may, as a rule, be avoided. Suturing 
a bone in this way does not require anesthesia. 

Among the rarer fractures occurring in the lower jaw 
may be mentioned fracture of the articular process (Plate 
16), and the rare accident of fracture by muscular action 
(temporal muscle) of the coronoid process. Such a frac- 
ture usually leaves considerable separation of the frag- 
ments after union has taken place. 



DISLOCATIONS OF THE LOWER JAW 

(A) Forward Dislocation 

Bilateral anterior dislocation of the lower jaw is a very 
common accident ; it occurs when the mouth is widely 
opened, as in yawning, vomiting, etc. Every physiologic 
movement of the lower jaw is associated with displacement 



106 FRACTURES AND DISLOCATIONS. 

PLATE 17. 

Anterior Dislocation of the Lower Jaw. — Fig. 1. — Double 
dislocation of the lower jaw, artificially produced and prepared in the 
cadaver. The mouth is wide open and the chin is displaced forward. 
The articular process of the lower jaw is in front of the articular tuber- 
cle. Behind the latter is the empty glenoid fossa. The capsule is 
greatly distended but uninjured. The temporal muscle is in extreme 
tension, as there is a marked dislocation forward of its point of inser- 
tion, the coronoid process. Thus the action of the temporal muscle 
causes an actual buckling of the articular process against the anterior 
surface of the articular tubercle. (Author's preparation.) 

Fig. 2. — Normal condition of the articulation of the jaw when the 
mouth is open. The articular process lies on the articular tubercle. 

Fig. 3. — Normal relations of the articulation of the jaw when the 
mouth is closed. The temporal muscle is relaxed. 



of the articular extremity. When the mouth is open, the 
head of the bone emerges from the glenoid fossa and rests 
on the articular tubercle. The axis for this movement — - 
i. e., the line of least movement in the lower jaw during 
this act — corresponds approximately with the beginning of 
the inferior dental canal at the lingula. In forced move- 
ments the articular extremity may be pushed beyond the 
articular tubercle and glide into another depression, where 
it then becomes firmly lodged ; in other words, a disloca- 
tion is produced. The accident is more frequent in women 
than in men. The fixation of the head of the bone is 
enhanced by the vigorous contraction of the muscles, espe- 
cially the temporal. 

The symptoms of dislocation of the jaw are extremely 
simple. The mouth is widely opened ; the alveolar process 
of the lower jaw projects far beyond that of the upper 
jaw ; the patient is utterly unable to close the mouth ; and 
the absence of the prominence of the condyloid process 
from its normal position and its presence further forward 
are readily detected. In unilateral anterior dislocation the 
mouth is also wide open and the chin is slightly displaced 



*N 




Tab. 17. 






Fiff.l. 




Fig..'], 




Pig.S. 

Lith.Ansi /-.' Reitflhold, Munch en . 



INJURIES OF THE FACIAL BONES, 



107 



toward the uninjured side. The capsule of the joint, as 
a rule, is not torn, but becomes greatly distended (Plate 
17). This dislocation does not occur in children. The 
prognosis is favorable, although a marked tendency to 
recurrence is frequently observed. It is termed habitual 
dislocation of the lower jaw. 

It follows from what 
has been said that a 
special manipulation is 
necessary to effect re- 
duction. The surgeon 
inserts his two thumbs 
into the mouth and 
lays them on the alve- 
olar processes of the 
lower jaw; the bone 
is then pressed first 
downward and then 
somewhat backward. 
In this way the ar- 
ticular extremity is 
pushed back until it 
rests on the articular 
tubercle, and finally 
into the glenoid fossa, 
and the dislocation is 
reduced. The sudden 
disappearance of the 
muscular resistance, 

which produces the fixation of the head of the bone, is 
plainly felt as the luxation is reduced. 




Fig. 27. — Action of the external ptery- 
goid muscle in dislocation of the lower 
jaw. 



(B) Backward Dislocation 

Backward dislocation of the lower jaw is an extremely 
rare occurrence, and is observed almost exclusively in 
women. The accident occurs after yawning or spasmodic 



108 



FRACTURES AND DISLOCATIONS. 



contraction, during a fall, etc. The condyloid process is 
forced behind the small tympanic tubercle which forms 
the posterior boundary of the glenoid fossa and enters the 
tympanico-stylo-mastoid fossa. The mouth is tightly 
closed ; the teeth of the lower jaw are behind those of the 




Fig. 28. — Method of reducing a dislocation of the lower jaw. 



upper jaw and tightly clenched. The articular process is 
found beneath the external auditory meatus in front of the 
mastoid process. Reduction is effected by pressing the 
jaw backward, and then downward and forward, or the 
teeth may be forcibly separated with any suitable instru- 
ment. [Anesthesia is usually necessary. — Ed.] 



FRACTURES OF THE VERTEBRAL COLUMN. 109 



IV. FRACTURES AND DISLOCATIONS OF THE VER= 
TEBRAL COLUMN 

(A) FRACTURES OF THE VERTEBRAL COLUMN 

i. Fracture of the Body of a Vertebra 

We may speak of a typical fracture of the body of a 
vertebra, such as that occurring in the region of the fifth 
and sixth cervical, of the last thoracic, and of the first 
lumbar, these being the most frequent. The accident is 
always produced by great violence. That the force must 
be great is readily understood when we consider that the 
vertebral column, in addition to a considerable degree of 
rigidity, possesses marked elasticity and mobility, since 
one-fourth of its entire length consists of the elastic and 
extremely movable intervertebral discs. The degree of 
mobility that can be attained by exercise is shown by the 
astonishing performances of so-called india-rubber men, 
who are able to bend almost double in the cervical region, 
at the junction between the thoracic and lumbar portions, 
and in the lumbar region of the column. These points 
also correspond with the most frequent sites of fracture, 
evidently because a bending force here finds the most 
favorable point of attack. This may be further illustrated 
by the fact that a rod of variable flexibility, like the ver- 
tebral column, when subjected to a breaking strain, usu- 
ally breaks at a point where one of the more flexible seg- 
ments joins a more rigid one; i. e., in the region of the 
twelfth thoracic and first lumbar, and particularly in the 
region of the lower cervical vertebrae. 

Direct fracture of the body of a vertebra is extremely 
rare. In all such cases of fracture of a vertebra by 
a violent blow or a wagon wheel, indirect violence is always 
a causal factor. 

Indirect fractures very commonly affect the bodies of the 



110 FRACTURES AND DISLOCATIONS. 

PLATE 18. 

Fracture of the Cervical Portion of the Column with 
Contusions of the Cord. — Fracture in the region of the sixth and 
seventh cervical vertebrae. From a woman thirty-three years old, 
admitted to the Greifswalder Klinik on June 28, 1893; died on July 5th. 
At the autopsy a complete transverse contusion of the cord was found. 
During life consciousness was preserved and there were sensory and 
motor paralyses of the trunk and lower extremities, with partial par- 
alysis of the upper extremities. The limits of sensation were found, 
in front, at the level of the third rib on both sides. There was also 
retention of urine. In the region of the sixth cervical vertebra a 
distinct prominence was felt which could be reduced under anesthe- 
sia. The injury was treated by the extension method, weights being 
attached to the head by means of a jury-mast (Glisson's sling). The 
patient was kept on a surgical bed provided with a water-mattress and 
a contrivance for raising and lowering. Death from paralysis of res- 
piration. 

The illustration shows the fracture of the two vertebrae and the 
dislocation backward and upward of the seventh, which encroached 
on the spinal canal and pressed upon the cord. (Author's observa- 
tion.) 

vertebrae and are produced by excessive flexion or exten- 
sion, by compression, or by a dislocating force — usually by 
a combination of all these factors. The accident is always 
produced by an overwhelming force, such as a fall on the 
back, the head, the buttocks, or the feet, or a cave-in, etc. 
In some cases it occurs while the vertebral column as 
a whole is fixed by the action of the muscles. Indirect 
fractures of the vertebrae by compression are compara- 
tively frequent among coal-miners. The injury is usually 
produced while the miner is bent over in a sitting posture, 
with the buttocks resting on the heels, by a mass of stones 
or coal falling on his head and neck from an inconsiderable 
height. Thus he is gradually bent over forward and com- 
pressed, excessive forward flexion of the vertebral column 
takes place until the head comes in contact with the knees, 
and a fracture is produced. 



Tab. 18. 



| 



m^r* 



,m: 



0fe\ I 



* 





Lith. Aftst. /: Rewhhold Munch en . 



FRACTURES OF THE VERTEBRAL COLUMN. Ill 

Various forms of fracture of the body of a ver- 
tebra are distinguished : 

Oblique fractures are the most common, and show a ten- 
dency to marked dislocation (compare Plate 18). The 
line of fracture is usually directed from above and behind, 
forward and downward. 

Longitudinal fractures are extremely rare. 

Transverse fractures are observed in so-called contusion- 
fractnres or compression-fractures of the vertebral column ; 
they occur when the column is subjected to extreme 
flexion and simultaneous compression in its long axis. 
The least resistant vertebra is compressed by its neighbors 
on either side; its transverse diameter is increased while 
its vertical diameter is shortened. True impacted frac- 
tures and fissured fractures also occur. Although the outer 
contour of the vertebral column is, as a rule, but slightly 
altered in these compression-fractures, a marked narrowing 
of the spinal canal and contusion of the cord may never- 
theless take place, as shown on Plate 19. Fissures and 
partial or even complete separation of the intervertebral 
discs have been observed. 

Symptoms. — A significant phenomenon in fracture of 
the vertebrae, besides the shock with which such a serious 
injury is often attended, is the traumatic kyphosis at 
the seat of fracture. It is the outward expression of dis- 
placement of the fragments with shortening of the entire 
vertebral column, and is produced partly by the injuring 
force and partly by the contraction of the powerful longi- 
tudinal muscles and by secondary movements. An angu- 
lation on the posterior aspect of the vertebral column is 
thus produced which is recognized by the characteristic 
prominence of the affected spinous process. If the frac- 
ture is oblique instead of transverse, a lateral dislocation 
may also take place, corresponding with the direction 
of the fracture. 

A slight grade of kyphosis is often difficult to recognize. 
Sometimes there is an absence of prominence, and the 



112 FRACTURES AND DISLOCATIONS. 

PLATE 19. 
Double Compression =fracture of the Vertebral Column. — 

The specimen was taken from the cadaver of a roofer, thirty years of 
age, who fell from a height of about 60 feet on the 28th of May, 1894. 
It was said that he first struck with his back against a ladder and then 
fell on his feet on the gravel beneath. The patient did not recover 
consciousness until the following day (in the clinic). On admission, 
there was pain in the upper and lower segments of the thoracic portion 
of the column ; there was no motor paralysis, but sensation was lost 
on the posterior aspect of the thighs, on the perineum, genitalia, and 
buttocks. After the second day urine and feces were discharged in- 
voluntarily. The case was complicated by a typical compression-frac- 
ture of the os calcis on the left side, a deep wound of the soft parts on 
the posterior portion of the sole of the right foot, and fracture of the 
right ankle. The subsequent course was marked by decubitus, ery- 
sipelas, and amputation of the leg, etc. Death supervened on 
November 11, 1894. (See Enderlen, in Deutsche Zeitschr. f. Chir., 
vol. xliii, p. 329.) 

The picture gives a faithful reproduction of the double compression- 
fracture ; the anterior border of the fifth thoracic vertebra is pressed 
into the sixth ; the vertebral canal at this point is intact (Fig. la). 
The body of the first lumbar vertebra appears completely crushed, the 
lines of fracture running in all directions. This has produced a 
marked narrowing of the vertebral canal, which at this point measures 
only 4 mm. in the sagittal diameter. The cauda equina and its cov- 
ering are involved at this point (adhesions) (Fig. 1 b). 

The fractures were produced by longitudinal compression of the 
vertebral column in marked antero flexion. (Author's observation.) 

kyphosis can only be recognized by the diminution of the 
normal lordosis or normal curve of the back. The diag- 
nosis in such cases may be indicated by localized pain on 
pressure, or transmitted pain by pressure or a blow on the 
head or shoulder, while the patient is sitting or standing. 
Abnormal mobility is, of course, never present and crepitus 
very rarely. 

Accessory injuries of the spinal cord or of the nerves that 
make their exit through the intervertebral foramina may 
be present in spite of the fact that the spinal cord is 



Tab .19. 








Fiff.1, 



> x i*f4§r 




<3HB 





: - 



r^.i 6 




Z&rt, .4/*.tf. /-.' Retrtihold. Mm 



FRACTURES OF THE VERTEBRAL COLUMN. 113 

securely incased in its canal formed by the bony arches 
and stout ligaments of the vertebrae and further protected 
by its covering of dura mater and free suspension within 
the cerebrospinal fluid. Fracture of a vertebral body with 
displacement of the fragments frequently produces more 
or less contusion of the cord. If the contusion involves 
the entire thickness of the cord, the most prominent symp- 
tom will be loss of motion and sensation in the region 
over which the injured segment presides, and we have : 
Paralysis of the rectum and bladder ; paraplegia of the 
lower extremities if the injury is in the thoracic portion 
above the lumbar enlargement ; motor and sensory paraly- 
sis of the trunk and upper extremities, marked disturb- 
ance of the respiration, sometimes excessive elevation of 
the body-temperature, if the injury is in the lower cer- 
vical portion ; early death from injury to the respiratory 
center, if the lesion occupies the upper cervical portion. 

In addition, motor paralysis in the distribution of the 
sciatic nerve is observed in injuries involving the lumbar 
enlargement (at the level of the spinous process of the 
twelfth thoracic vertebra) ; paralysis of rectum and blad- 
der ; impairment of sexual power ; local anesthesia of 
the anal and perineal region, of the genitalia, and of the 
posterior aspect of the thigh, when the lesion is below the 
third lumbar vertebra. In this localization the cauda equina 
alone is affected. The condition of the reflexes is vari- 
able ; as a rule, they are obliterated when the entire cord 
is injured by contusion or other analogous compression. 
If the injury is slight, they may be unchanged or even ex- 
aggerated. 1 

The diagnosis of fracture of the body of a vertebra in 
very severe cases can hardly be mistaken. If the degree 
of injury is known, if the kyphosis is readily recognizable 
and the symptoms of transverse lesion of the cord are 
present, the diagnosis is assured. But nervous phenomena 

1 For further details see the instructive monograph of Trapp 
(Deutsche Zeitschr. f. Chir., vol. xlv, p. 434). 



114 FRACTURES AND DISLOCATIONS. 

need not necessarily be present in fracture of the body of a 
vertebra, and we must insist that the spinal cord and 
nerve-trunks escape injury in many cases. A glance 
at the fracture in the upper thoracic portion of the verte- 
bral column represented on Plate 19 (Fig. 1 a) shows that 
the cord at this point is quite intact. In these cases the 
force is only a moderate one and the kyphosis is less dis- 
tinctly marked. To detect the latter, careful examination, 
especially by inspection, is necessary ; the least deviations 
from the normal curvature of the vertebral column, such as 
accentuation of the curve, the presence of a prominence at 
the seat of injury, and flattening of the adjacent portion, 
must be looked for. If the examination is made some little 
time after the injury, functional disturbances, local pain on 
pressure, and pain elicited at the suspected spot by sudden 
pressure on the head in the direction of the vertebral col- 
umn, are valuable diagnostic data. Ability to stand or 
walk, or even to do light work, does not absolutely exclude 
fracture of the vertebra, especially a compression-fracture. 
If grave symptoms develop later on, they are due to loosen- 
ing of the impaction at the seat of fracture and to alterations 
in the fragments, such as occur in every variety of fracture. 
The prognosis depends on the character of the acces- 
sory injuries and their consequences. As far as the frac- 
ture itself is concerned, it may heal by bony union, and 
many patients live on undisturbed and are able to do more 
or less work, provided only the spinal cord has not been 
injured. If, on the other hand, the symptoms of cord- 
lesion are present, the case immediately becomes very 
grave. Even if myelitis is warded off, other dangers 
threaten. Bladder paralysis, as a rule, calls for the use of 
the catheter several times a day, and while perfect asepsis 
should always be insisted upon and is not impossible of 
attainment, there is nevertheless great danger in actual 
practice of cystitis developing through infection by the 
catheter and resulting in septic pyelonephritis which 
eventually ends the patient's life. 



FRACTURES OF THE VERTEBRAL COLUMN. 115 




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116 FRACTURES AND DISLOCATIONS. 

Another danger lurks in the anesthesia of the paralyzed 
portions of the body. Pressure gangrene may result not 
only from the grave trophic disturbances, such as occur 
especially in lesions of the cervical portion of the cord and 
rapidly produce pressure sores, but also from the anesthe- 
sia itself, especially in regions that are constantly exposed 
to pressure and moisture, as in the sacral region. There 
is no condition that requires more careful nursing and 
more constant supervision on the part of the surgeon than 
fracture of a vertebra with paralysis of a large portion of 
the body. The patient must be provided with a soft 
mattress free from folds, the sacral region, the heels, etc., 
being especially protected by means of water-pillows or 
cushions filled with millet chaff. The patient's position 
must be changed by turning him slightly, first on the right, 
and then on the left side. The bed must be kept scrupu- 
lously clean and dry, and the skin gently washed with 
alcohol, bichlorid solutions, etc. The urine, as has been 
stated, must be evacuated with every aseptic precaution. 
The state of the bowels requires supervision. Diarrhea is 
a most unfavorable symptom when incontinence of the 
alvine discharges exists. In a hospital, where patients of 
this class ought always to be treated, special apparatus is 
at hand, such as a surgical bed with a contrivance for 
raising and lowering, and provided with an opening for 
the discharge of the stools ; permanent water-bath, etc. 
The nearer the lesion to the upper extremity of the verte- 
bral column, the more unfavorable is the prognosis, because 
the injury at this level threatens interference with vital 
organs. Hence fractures in the cervical portion are in 
general much more dangerous than those in the lower thor- 
acic and lumbar regions. 

Treatment. — Intelligent treatment should be instituted 
from the moment of the patient's admission. He must 
not be allowed to sit or stand on account of the danger of 
secondary displacement of the fragments and injury of the 
as yet uninjured cord, especially if the fracture is oblique 



FRACTURES OF THE VERTEBRAL COLUMN. 117 




Fig. 30. — Angular kyphosis in 
the region of the eighth and ninth 
thoracic vertebrae after a fall on 
the back (on May 24, 1894) from 
a height of 5 meters. The man 
landed on a pile of bricks. After 
the primary loss of consciousness 
cleared up, the patient was able, 
with the assistance of his com- 
panions, to walk to his home, 
which was in the neighborhood. 
On May 30th the man, who was 
thirty -eight years of age, was ad- 
mitted to the clinic. There was 
pain at the seat of fracture ; no 
nervous symptoms. 




Fig. 31. — Showing the same 
patient with a plaster-of-Paris 
jacket which somewhat relieved 
the strain on the seat of fracture. 
If the fracture is located in the 
region of the last thoracic, or 
lumbar vertebra, the jacket must 
reach further down on the pelvis ; 
i. e.j have more of a hold on the 
pelvis. 



118 FRACTURES AND DISLOCATIONS. 

and due to direct violence. The patient must be carefully 
laid on a stretcher and then put to bed. The seat of frac- 
ture itself does not always require special attention. In 
fractures of the cervical portion the seat of fracture may 
be put at rest by applying permanent extension by means 
of weights with a Glissoir's sling (jury-mast) to the head. 
The head is best laid on a sliding rest like a sliding foot- 
board (Volkmann's rest). Sometimes the patients are 
more comfortable in the simple dorsal position, with a pil- 
low under the head. 

Even in fractures of the thoracic and lumbar portion 
of the column permanent extension by traction on the 
head and pelvis may be utilized to maintain separation of 
the fragments. I am in the habit of using a kind of belt 
to which the extension apparatus is attached. The appli- 
cation of a plaster-of-Paris jacket immediately after the 
injury, while the patient is suspended in a Sayre's appara- 
tus, has been attended with good success, but it is a pro- 
ceeding which is not altogether without danger. Recently 
an experienced and trustworthy authority (Poller de- 
scribes Fuller's views and methods in the Arch, fur klin. 
Chir., vol. liv, p. 289) has recommended forcible reduc- 
tion of the displaced fragments, by means of forced exten- 
sion of the vertebral column and pressure with the hand 
on the kyphosis, in all cases of fracture from compression 
characterized by marked kyphosis at the seat of fracture. 
The procedure requires full anesthesia. It is better at 
first merely to place the patient in the proper posture and 
apply extension by means of weights; after a time, rigidity 
of the head and back may be secured by means of a heavy 
plaster-of-Paris gutter fitted on while the patient lies on 
his face. Later, a suitable supporting apparatus, such as 
a plaster-of-Paris jacket, is necessary. Surgical inter- 
vention to relieve the pressure on the cord (laminectomy) 
is indicated only in very rare cases, as when fragments 
of the vertebral arch have entered the cord from behind, 
provided the condition can be diagnosed. (Goldschneider.) 



FRACTURES OF THE VERTEBRAL COLUMN. 



119 



Even in milder cases, in which there is no injury of 
the cord, such as contusion or ecchymosis near the nerves 
that make their exit from the vertebral canal, the treat- 
ment should be carried out 
with the minutest care. To 
bring about bony union of 
the fragments and avoid 
secondary displacement re- 
quires a long period of 
rest in the proper posture 
and the wearing of well- 
fitting supportive apparatus 
for an indefinite time after- 
ward. The strain on the 
body of the vertebra in the erect posture and in doing 
work is enormous, while the formation of new bone is not 
very abundant. We know from recently reported cases 




Fig. 32.- 



-Fracture of a spinous 
process. 




Fig. 33.— Fracture of the 
arch of the fifth cervical verte- 
bra by a wagon wheel. The 
body of the vertebra is intact. 
(Pathol. -Anat. Institute at 
Greifswald.) 




Fig. 34. — Seventh cervical verte- 
bra; fracture of the arch and spin- 
ous process. 



that a relatively slight injury of the vertebral column may 
be followed by secondary changes with grave symptoms 
and functional disturbances. To explain this phenomenon 



120 



FRACTURES AND DISLOCATIONS. 



the occurrence of inflammatory changes at the seat of 
fracture — L e., a traumatic spondylitis (Ktimmell) — has 
been assumed ; but in view of the occurrence of analogous 
processes in other fractures, and especially in view of 
the relatively frequent occurrence of fracture of the body 
of a vertebra without serious symptoms, this assumption 
does not appear justifiable. In these cases the symptoms 
must be regarded as due to secondary disturbances 
developing at the seat of a slight fracture of the vertebra 
which had at first been overlooked. 

2. Fractures of the Vertebral Column or Spinous 

Processes 

These fractures are rare, and when they do occur, are 
usually combined with fracture of the body of the verte- 
bra. We distinguish : 

Fracture of the spinous process by direct violence, espe- 
cially in the thoracic region, attended usually with marked 
displacement. 

Fracture of the transverse or oblique processes — extremely 
rare. 

Fracture of the vertebral arch — rare, but possible in the 
lower cervical vertebrae by direct violence ; a piece of the 
arch may give way with a fracture of the spinous process 
and become displaced against the vertebral canal, making 
operative intervention necessary. 



(B) DISLOCATIONS OF THE VERTEBRAL COLUMN 

The anatomic relations are such that dislocations of the 
vertebral column in the thoracic and lumbar regions are 
exceedingly rare. In the cervical region, on the other 
hand, dislocation is more common and is of great prac- 
tical significance. 

If the cervical vertebrae of the skeleton are arranged in 
their proper order, and a heavy rubber tube is drawn 



DISLOCATIONS OF THE VERTEBRAL C0LU3IN. 121 

through the vertebral canal so as to bring the individual 
vertebrae into contact with one another, it is quite easy, by 
stretching the rubber tube, to produce first a separation 
and then a luxation of two of the vertebrae. There is no 
better way of learning the pathologic anatomy of a luxa- 
tion. 

We distinguish between flexion- and rotatory luxations 
of the cervical vertebrae (Hueter). In the first class the 
dislocation is produced by forced flexion of the head on 
the chest. The posterior borders of the vertebrae are 
thus forced apart ; the ligaments, including those on the 
articular processes, are stretched and finally torn ; and by 
a simultaneous forward displacement of the upper verte- 
brae luxation is produced (Plate 20, Fig. 2). Rotatory lux- 
ation may be described as a unilateral flexion-luxation, 
although it is not produced by flexion, but by abduction 
toward the side which remains uninjured and anterior ro- 
tation of the upper border (Plate 20, Fig. 1). 

The symptoms are often quite characteristic : In flex- 
ion-luxations there is a characteristic interruption of the 
line of the spinous processes, and occasionally, it is said, 
the projecting body of the vertebra can be felt by intro- 
ducing the finger in the mouth ; there is always marked 
flexion of the neck forward, with vertical position of the 
head. In rotatory luxations the head is inclined and 
slightly rotated toward the unaffected side ; the interrup- 
tion in the line of the bodies of the vertebrae and of the 
spinous processes is much less marked. Injury to the 
cord is possible in these dislocations ; their consequences 
are the same as those that attend fractures of the vertebrae, 
and have already been discussed. Injury to the phrenic 
nerve does not occur when the dislocation is below the 
fourth cervical vertebra. 

The prognosis depends on accessory injuries and on the 
completeness with which reduction has been effected. In 
rotatory luxations accessory injuries may be absent. 

Treatment. — The dislocation must be reduced under 



122 FRACTURES AND DISLOCATIONS. 

PLATE 20. 

Dislocation in the Cervical Portion of the Column. — These 
illustrations were made from specimens in which the dislocation had 
been produced artificially. 

Fig. 1 a and b. — Unilateral dislocation (rotatory luxation) in the 
cervical portion of the column, seen from the side and from behind. 
The fourth cervical vertebra is dislocated in such a manner that the 
articular process, on the left side, overrides and projects in front of 
that of the fifth. The luxation was produced by abduction ; i. e., 
movement to the right, or anterior rotation. The two processes be- 
came firmly locked. The prominence of the body of the fourth ver- 
tebra is seen (lateral view), and the inclination of the upper vertebra 
and of the head to the right (posterior view). 

Fig. 2 a and b. — Bilateral dislocation in the cervical portion of the 
column (flexion-dislocation), seen from the side and from behind. 
The body^ of the fourth vertebra projects some distance in front of the 
fifth; the line of the vertebral column is perpendicular. (Author's 
preparation.) 

full anesthesia. In rotatory luxation reduction is effected 
by means of abduction toward the uninjured side so as to 
overcome the locking of the processes, followed by back- 
ward rotation of the head on the injured side. In per- 
forming abduction not only the head, but all that portion 
of the neck above the dislocated joint, must be firmly 
held and properly supported. In a flexion-luxation the 
two sides are successively treated and reduced as in a 
rotatory luxation. After the dislocation has been reduced 
the parts must be kept rigid for several weeks by means 
of some appropriate dressing, such as a stiff collar. 

Of the remaining dislocations occurring in the cervical 
portion of the cord, luxation of the head (between the 
atlas and the occiput) by excessive flexion or extension of 
the head, and luxation of the atlas (between the atlas and 
axis) may be mentioned ; in both these luxations death 
usually results from accessory injuries. 

Dislocations in the thoracic and lumbar regions are 
extremely rare. Their occurrence has, however, been 



Tab. 20. 




Ltih incite 



FRACTURES OF THE THORAX. 123 

unmistakably proved in the postmortem room. During 
life they cannot be recognized ; that is to say, it is hardly 
possible to exclude fracture. Anterior, posterior, and so- 
called abduction-luxations have been observed. 

The prognosis is unfavorable owing to injury of the 
cord. Attempts at reduction should be made by extension 
and counterextension and direct pressure. 



V. FRACTURES OF THE THORAX 
(A) FRACTURES OF THE RIBS. (Plates 21 and 22.) 

Owing to the great mobility of the lowest ribs and the 
position of the upper ones, protected as they are by the 
overlying muscles and clavicle, fractures in these two 
divisions are comparatively rare. Excluding these, how- 
ever, fracture of the ribs is a very common accident, and 
constitutes about 15 fo of all fractures. In children, owing 
to the exceeding elasticity of the ribs, fractures are very 
rare. 

Fractures of the ribs are produced by direct and by 
indirect violence when the thorax is compressed either in 
its transverse or in its antero-posterior diameter. Multi- 
ple fractures occur chiefly in the axillary line and at the 
angles of the ribs. 

The diagnosis is based not so much on the displace- 
ment of the fragments as on the presence of pain and 
crepitus on pressure which is frequently audible. The lung 
is often injured. It may be directly perforated by a sharp 
fragment at the time of the fracture ; and as the costal and 
pulmonary pleurae are injured at the same time, hemothorax 
and pneumothorax may take place. Traumatic cutaneous 
emphysema is frequently present, beginning at the seat of 
fracture, and, in severe cases, extending to the cellular tis- 
sue of the entire body. The air escapes into the pleural 
cavity from the alveoli and tertiary bronchi of the injured 



124 FRACTURES AND DISLOCATIONS. 

PLATE 21. 

Fractures of Ribs. — Fig. 1. — Fracture involving the third to the 
tenth ribs on the right side. This beautiful preparation, which was 
taken from a man fifty-three years of age, shows numerous fractures. 
The right half of the thorax sustained a linear fracture involving the 
above-named ribs, corresponding approximately to the middle of the 
affected ribs not counting the costal cartilage ; or, in other words, to 
the axillary line. In all but the eighth and tenth ribs the fracture is 
found in this line. In addition, the four lower ribs of the preparation 
— i. e. y the seventh, eighth, ninth, and tenth — were fractured at the 
angle, with considerable displacement ; the two upper ones show the 
traces of an infraction at the same point. 

The case, therefore, is one of multiple fracture of the affected ribs. 
The fractures coincide with the axillary line and with the line of the 
angle of the ribs. It is evident at a glance that in the three lowest 
ribs of the preparation (eighth, ninth, tenth) the fractures in the axil- 
lary line have united without displacement, while those at the angle 
present marked displacement. The fourth, fifth, sixth, and seventh 
ribs present marked deformity (there had been overriding of the frag- 
ments in the axillary line), while at the angle no deformity is 
apparent. The third rib was broken only in the axillary line and 
shows good union. 

Fig. 1 a. — Horizontal section of the fourth rib (axillary) of the same 
preparation, showing the displacement and firm union. 

Fig. 2. — Recently united fracture of the ribs without displacement, 
shown in horizontal section. Callus-formation is well shown. 

portion of the lung, during both inspiration and expira- 
tion, and spreads from there in all directions. Unless 
the cutaneous emphysema is universal and becomes dan- 
gerous by reason of its extent, it is not a serious symptom. 
As a rule, it disappears by absorption within a few days. 
Hemothorax may require aspiration. 

Treatment. — Complications must be treated as they 
arise. The region of the fracture is supported with strips 
of adhesive plaster. Bony union takes place, usually 
without marked displacement, and in almost every case 
with only temporary disability. After a fracture of the 
upper ribs the carrying of heavy burdens on the shoulder 



Tab. 2/. 













■•"«L«fccf. 



LUh.Arist F. Reichhold , Sfunchen. 



FRACTURES OF THE THORAX. 125 

may continue to cause great distress for an indefinite 
period. 

Fractures of the costal cartilages are not as rare as might 
be supposed. The fracture occurs at the junction between 
the cartilage and the rib (see Plate 22, Fig. 2), or in the 
body of the cartilage itself (Plate 22, Fig. 1). The latter 
specimen demonstrates that a fracture of this kind may 
leave considerable deformity and unite with a scanty for- 
mation of callus. The fracture is predisposed to by dimin- 
ished elasticity of the cartilage, due to senile changes, and 
is usually produced by direct violence ; it occurs most fre- 
quently in those cartilages which are most exposed — 
namely, the fifth to the eighth. 

The symptoms are the same as in fracture of the ribs, 
except that crepitus is of a softer character. 

DISLOCATION OF THE RIBS 

This extremely rare injury needs only a passing refer- 
ence. It may occur in the form of a luxation of the costal 
cartilages at the sternal extremity or of the costo- vertebral 
articulations, or, finally, as a dislocation at the junction of 
two costal cartilages. Reduction is effected by direct pres- 
sure or movement, as, for instance, deep inspiration. 



(B) FRACTURES OF THE STERNUM. (Plate 22.) 

They are produced by direct violence, and are then dan- 
gerous on account of injury to the internal organs, or by 
indirect violence in flexion of the vertebral column or of 
the head so that the chin presses against the upper edge 
of the sternum. In the latter variety the sternum is com- 
pressed in its longitudinal axis until it snaps. Sometimes 
the combination of fracture of the cervical portion of the 
vertebral column and fracture of the sternum is produced 
in this way. Fracture of the sternum has also been 
known to occur after overextension of the trunk ; that is 



126 FRACTURES AND DISLOCATIONS. 

PLATE 22. 
Fracture of the Costal Cartilages and of the Sternum.— 

Fig. 1. — Fracture of the costal cartilages; horizontal section; marked 
displacement of the fragments, which are united by a scanty formation 
of bone. (Path.-Anat. Inst., Greifswald. ) 

Fig. 2. — Fracture of the costal cartilages at the bony portion of the 
fifth rib ; horizontal section ; no displacement. The union is not 
bony; it rather resembles a false joint. (Path.-Anat. Inst., Greifs- 
wald. ) 

Fig. 3. — Recent fracture of the sternum, artificially produced in 
the cadaver in imitation of a similar fracture observed by the author. 

Fig. 4. Fracture between the manubrium and gladiolus; union 
with displacement of the fragments. (After Gurlt.) 

to say, by muscular action. Owing to the superficial posi- 
tion of the bone, the diagnosis presents no difficulties, 
especially when there is anterior or posterior displacement 
of the fragments. 

Treatment. — In two recent cases under my care I was 
able to reduce the displacement of the fragments, as is 
shown in the picture, by extension applied to the head with 
Glisson's sling; extension was maintained by supporting 
the thorax on a wedge-shaped cushion and the head was 
placed in slight overextension. 



VI. FRACTURES AND DISLOCATIONS OF THE 
UPPER EXTREMITY 

Injuries to the upper extremity are either direct or indi- 
rect. Injuries due to direct violence present certain defi- 
nite characteristics, and their presence can often be recog- 
nized by a knowledge of the cause alone; on the other 
hand, injuries due to indirect violence, even when produced 
by the same cause, present a great variety of forms. Thus, 
a fall on the hand may be followed by a typical fracture of 
the lower extremity of the radius, by an injury to 
the elbow ; -joint, the upper end of the humerus, or the 



Tab. 22. 







. 



Fiq.J. 





Fig. 4r. 



FRACTURES OF THE UPFEB EXTREMITY. 127 

shoulder-joint; in children the accident may even produce 
a fracture of the clavicle. 



i. CLAVICLE 

(A) Fracture of the Clavicle 

is a common accident, constituting about 15% of all 
fractures. The fracture may occupy any portion of the 
bone, but is most frequent at about the middle, usually a 
little nearer the sternal extremity. Fracture of the clavicle 
is, as a rule, produced by indirect violence, by a fall on 
the hand while the elbow- and shoulder-joints are fixed, or 
by a fall on the shoulder, the bone being bent until 
it breaks. Owing to the fact that the clavicle comes in 
contact with the first rib when the shoulder is strongly 
depressed, fracture of the bone at this point is said to be 
produced by the downward pull on the arm in lifting 
heavy weights. Incomplete fractures (infractions) are 
frequently observed at this point, particularly in children. 
The symptoms of a typical fracture of the clavicle are, 
as a rule, very characteristic. The displacement of the 
fragments depends both on the action of the muscles and 
on the weight of the arm. The sternal fragment is 
acted on by the sternocleidomastoid muscle and usually 
suffers some degree of upward displacement. The pull 
exerted by thr powerful muscles that connect the thorax 
with the arm causes a secondary approximation of the 
outer fragment and of the entire arm toward the thorax, 
for under normal conditions the clavicle acts as a 
brace maintaining the shoulder at the proper distance 
from the thorax. Hence in a typical fracture of the 
clavicle the arm hangs lower than on the sound side. 
Furthermore, the arm as a whole is brought nearer to 
the thorax, so that the axillary space is not as accessible 
as under normal conditions; and, finally, there is a for- 
ward and median inward displacement of the arm — a 



128 



FRACTURES AND DISLOCATIONS. 



PLATE 22 a. 
Normal Shoulder=joint of an Adult. Skiagraph.— The pic- 
ture is explained by figure 35. 



CLclvicuLcl 

Processus coracoidett 



CafviU humeri 



Caaitas glervoidatis 
(nvargo [uxsteriorJ 



ina scafiulcu 
(margo superior 

Basis sninae sca/uiCae 



ffumerus 




Fig. 35. 



kind of internal rotation, due evidently to the unopposed 
pull of the thoracic muscles. 

The diagnosis of a fully developed fracture of the 
clavicle is very simple, and is usually made by inspection. 
The displacement, the attitude of the arm, and the swell- 
ing at the seat of fracture are recognized at a glance. As 
the bone is very accessible, the displaced fragments can 
readily be palpated, and, in addition, the pain and func- 
tional disturbance usually point to the seat of injury. If 
the fracture is incomplete (infraction and fissure-fracture), 
displacement may be slight or entirely wanting. 



Tab. 22 a. 




FRACTURES OF THE UPPER EXTREMITY. 



129 



The treatment of these typical fractures of the clavicle 
demands, in the first place, accurate reduction, and, in 
the second place, a dressing that will counteract the 




Fig. 36. — United fracture of the right clavicle in a man thirty years 
of age. Seen from above and behind. There is an abundance of callus ; 
the inner fragment is displaced forward and upward, and overrides the 
outer fragment considerably. (Berliner Anat. Museum; after Gurlt. ) 




causes that produce the displacement. It is well known 
that union of a broken clavicle without deformity 
was formerly con- 
sidered one of the 
greatest rarities 
and a most difficult 
problem to solve. 

We now have 
means at our dis- 
posal which enable 
us, even in the 
severest cases, to 
secure union in a 
favorable position. 

To effect reduc- 
tion and maintain 
the fragments in 
position while the 

bandage is applied (Fig. 39), an assistant should stand 
behind the patient, who is seated in a chair, and forcibly 
draw the shoulders backward, helping himself if neces- 
sary by bracing his knee against the patient's back. An 
9 



Fig. 37. — Fracture of the right clavicle 
with displacement. The Sternal fragment 
projects slightly upward and distinctly for- 
ward (Muller, female, nineteen years old). 
The shortening of the right clavicle is recog- 
nized by the diminished width of the shoul- 
der on that side, measured to the median 
line. (Author's observation.) 



130 FRACTURES AND DISLOCATIONS. 

PLATE 23. 
Fracture of the Clavicle with Typical Displacement of the 
Fragments. — The seat of fracture is at the junction between the 
sternal and middle third of the bone. The fragments present marked 
" overriding." The sternal fragment is displaced upward by the 
pressure of the outer fragment and the pull of the sternocleidomastoid 
muscle. In the illustration the sternocleidomastoid muscle is readily 
recognized ; behind, the outer boundary of the neck is formed by the 
trapezius muscle ; the deltoid is dissected out and the clavicular por- 
tion of the pectoraiis major has been in part removed. Within the 
fenestra thus produced we see the fractured clavicle with the subcla- 
vian muscle hugging its lower surface and the first rib. Behind the 
clavicle the large vessels and nerves are shown. As a result of the 
fracture the arm is brought nearer to the trunk, and the axillary 
cavity therefore contracted ; the arm hangs down, the right elbow 
being lower than the left. 

appropriate dressing is the adhesive plaster dressing 
devised by Sayre ; it consists of three strips of adhesive 
plaster, two of which are used to correct the above- 




Fig. 38. — Recent fracture of the outer half of the right clavicle 
(Schroder, male, sixty years old). Marked deformity; the larger, 
median fragment projects upward; the outer fragment is depressed 
along with the entire shoulder. The width of the shoulder is dis- 
tinctly diminished. (Author's observation.) 

described displacement. The first strip corrects the 
internal rotation of the arm. It is wrapped around the 
upper extremity of the arm from the inner to the outer 



Tab. 2,1. 






JMh.An.sl !■: Keichluihl '. Miinchen.. 



FRACTURES OF THE UPPER EXTREMITY. 



131 



side and passes over the shoulder to the back. The second 
strip is wrapped around the elbow and passed over the 
shoulder of the sound side so as to support the injured 
arm. The third strip acts merely as a sling to support 
the hand; being passed 
over the injured shoulder. 
Incidentally it exerts 
moderate pressure on the 
fragments from above and 
in front. One indication 
which is not met by this 
method is the restoration 
of the axillary space; /. c, 
of the normal distance 
between the shoulder and 
thorax. For this pur- 
pose a pad of some soft 
material, covered with 
gauze, should be placed 
in the axilla and fixed in 
some simple way. The 
dressing may be ad- 
va ntageously reinforced 
by a few turns of a roller 
bandage in order to 
enhance its effectiveness. 
At the same time a small 
pad may be fixed over 
the seat of fracture so 
as to produce a slight 
downward pressure on 
the sternal fragment. In 
the summer-time it is well to dust the area covered by the 
dressing, especially the axillary space, with toilet powder. 
The effectiveness of the adhesive-plaster dressing may 
be increased by incorporating two pieces of rubber ban- 
dage in the strips of adhesive plaster, and by exerting the 




Fig. 39.— Method of reducing a 
fracture of the clavicle and maintain- 
ing the fragments in place while the 
dressing is applied. 



132 



FRACTURES AND DISLOCATIONS. 



proper tension while they are being applied so as to pro- 
duce a continuous elastic pressure which prevents recur- 
rence of the displacement. The same thing may be 
accomplished by means of pieces of rubber tubing. With 
proper supervision of the patient these simple means will 

suffice to obtain satis- 
factory results, pro- 
vided the surgeon pos- 
sesses the necessary 
technical skill. It is 
much to be regretted 
that we still see a 
good many badly 
united fractures of the 
clavicle. Cases of 
multiple fracture and 
infraction should be 
treated on the same 
principles. 

[The most im- 
portant point in the 
treatment of fractures 
of the clavicle is to 
prevent the usual de- 
formity — lowering 
and falling forward 
and slightly inward of 
the shoulder. Sur- 
geons in this country 
prefer a somewhat 
more simple method 
of dressing than the one illustrated here (see Scudder's 
recent text-book). They also prefer the Velpeau posi- 
tion of the forearm. Personally, I prefer a plaster dress- 
ing with the arm in the Velpeau position, the hand 
out of the dressing. A properly fitted axillary pad is 
most important. This plaster dressing holds the shoul- 




Fig. 40. — Sayre's adhesive-plaster dress- 
ing for fracture of the clavicle. 



FRACTURES OF THE UPPER EXTREMITY. 



133 



der in its corrected position perfectly. A window can be 
cut over the site of the fracture to allow inspection* 





Fig. 41. Fig. 42. 

Figs. 41 and 42. — Adhesive-plaster dressing for fracture of the 
clavicle (first strip of Sayre's dressing) with interposed zinc plaster- 
mull, and intercalated strip of rubber bandage 




Fig. 43. — United fracture in the sternal third of the right clavicle, 
seen from above and behind. The oblique fracture is firmly united by 
callus. (Anat. Museum, Breslau; after Gurlt.) 



When properly applied over skin well dusted with mag- 
nesium powder, the dressing is worn with comfort for two 



134 FRACTURES AND DISLOCATIONS. 

PLATE 24. 
Dislocation of the Sternal Extremity of the Clavicle.— Fig. 

1. — Presternal luxation of the right clavicle, in a man fifty-seven years 
of age (Brackhahn, 1894-95, No. 1160) ; anterior view. There was 
also compound fracture of the forearm on the same side. In the illus- 
tration the prominence of the dislocated clavicle is well shown; the 
right shoulder is nearer the median line than the left. 

Fig. 1 a. — The same dislocation shown in the skeleton. 

Fig. 1 b. — Eetrosternal dislocation of the clavicle. A dislocation of 
the clavicle behind the sternum produces pressure on the trachea and 
esophagus, which may be followed by grave consequences. 

weeks. It has been my experience, especially in children, 
that only the plaster dressing remains fixed ; other dress- 
ings are very apt to work loose, and adhesive plaster ap- 
plied to large areas of skin in warm weather produces 
much more discomfort than the plaster dressing. — Ed.] 




Fig. 44. — United fracture of the acromial end of the right clavicle; 
seen from above and in front. The outer fragment is placed obliquely 
on end; the two fragments come together at an angle like the rafters 
of a roof . (Path.-Anat. Inst., Greifswald. ) 

Among complications there are injuries to the brachial 
plexus and, more rarely, injuries to the large vessels. 
Secondary injuries to the plexus may result from pressure 
of the callus ; because, owing to its position on the first 
rib, the plexus is unable to get out of the way. It very 
rarely happens in fracture of the clavicle that the dome of 
the pleura and apex of the lung become injured by a sharp 
fragment. 



Tab. 2 4. 



( 




ifyi. 




^v 




Fir/, la 



Fig. 1 b 



/,/t/i.Ans/. /:' ReiclihoUl. M 



FRACTURES OF THE UPPER EXTREMITY. 



135 



Fracture of the sternal segment of the clavicle is rare, 
and does not, as a rule, produce any deformity. 

Fracture of the acromial end of the clavicle sometimes 
produces marked deformity, the outer fragment being 
almost placed on end. It may be difficult to apply the 
bandage so as to keep both fragments in position, but good 
reduction and an elastic bandage are required. 



(B) Dislocations of the Clavicle 

(a) Sternal dislocation of the clavicle — I e,, dislo- 
cation of the sternal end of the clavicle — presents various 
forms : 

Anterior dislocation (luxatio prcesternalis). 

Upward disloca- 
tion (luxatio supra- 
sternalis). 

Both these vari- 
eties are produced 
indirectly by lever- 
age, the first rib 
acting as a ful- 
crum; or they may 
be produced by a 
force acting from 
without, depending 
on the position of 
the clavicle, 
whether it is di- 
rected backward 
or downward. In 
anterior disloca- 
tion secondary dis- 
placement may 
take place. 

Posterior dislo- 
cation {luxatio retrosternalis). 
duced by direct violence. 




Fig. 45. — Eecent fracture in the acromial 
third of the clavicle. The normal clavicle 
on the sound side measures 18 cm. in length. 
The inner fragment measures 16 cm., leaving 
2 cm. for the acromial fragment. The median 
extremity of the latter is distinctly raised and 
partially connected with the inner fragment, 
which is also displaced upward and can be 
distinctly felt under the skin. The patient's 
name was Warnke, sixty-eight years of age. 
(Author's observation in the surgical clinic 
at Greifswald, 1896. ) 



This 



is very rare ; it is pro- 



136 FRACTURES AND DISLOCATIONS. 

PLATE 25. 
Upward Dislocation of the Acromial End of the Clavicle.— 

Fig. 1. — The abnormal prominence of the clavicle is very conspicuous. 
To the outer side and below we see the normal rotundit} 7 of the shoulder 
with the acromion. The dislocation is seen even more plainly in the 
posterior view shown in figure 1 b. The line of the spine of the scapula 
is directed toward the acromion. The right shoulder is nearer the 
median line than the left, because the bracing action of the clavicle is 
lost. The right axillary space is contracted. 

Fig. 1 a shows an anterior view of the dislocation in the skeleton. 
(Author's specimens. ) 



The diagnosis is always easy, because all the conditions 
can be readily palpated. In the backward dislocation 
(Plate 24, Fig. 1 b) the pressure on the trachea and esoph- 
agus may lead to troublesome dyspnea and dysphagia. 
Dislocation is differentiated from fracture near the joint by 
following the normal spherical prominence of the bone and 
by measuring the length of the clavicle. 

Treatment. — Reduction is usually easy, but, on the 
other hand, it is difficult to maintain the fragments in 
position. Careful bandaging with direct pressure on 
the articular extremity after it has been replaced, and 
sometimes elastic bandages, as referred to under treatment 
of fracture of the clavicle, are indicated. In some cases 
the fragments may have to be fixed by means of a 
suture through the skin (percutaneous suture). [It is 
surely a better surgical procedure, when a bone is to be 
fixed by suture, to make a skin incision and approximate 
the fragments with a subcutaneous suture. The danger of 
infection is less, and with the open wound one can be more 
certain of the perfect approximation. — Ed.] 

(b) Acromial Dislocation of the Clavicle. — To be 
exact, this condition should be called dislocation of the 
scapula. The clavicle may be dislocated : 

Upward (luxatio mpra-acromialis), or 

Downward (luxatio infra-acromialis). 




Tab.2». 




Fig.l. 



^^*\ >w 





v 



1 



Fig I * 



Fig.l I? 
LithAmt t: Reich Iwld. Munchen , 



FRACTURES OF THE UPPER EXTREMITY. 137 

The latter is a very rare accident. The first variety is 
often produced by direct violence acting on the acromion 
while the clavicle is fixed. It is really a downward dis- 
location of the scapula. If after the coraco-clavicalar liga- 
ment is torn a marked displacement exists, the dislocation 
is complete. 

The diagnosis is easy, as the parts can be accurately 
palpated ; nevertheless, this dislocation is often confounded 
with dislocation of the humerus. Great care in the ex- 
amination is necessary to distinguish this dislocation from 
a fracture of the clavicle close to the acromial extremity. 
To establish the diagnosis between these conditions, the 
length of the clavicle must be accurately measured. To 
distinguish it from a typical dislocation of the shoulder 
a single manipulation by the surgeon seated in front of the 
patient suffices. If both hands are passed along the scap- 
ular spines from behind, they will, without fail, come upon 
the point of the acromion (Plate 25, Fig. 1 b) ; the position 
of the latter in relation to the abnormal prominence of the 
clavicle will at once clear up the doubt. 

Treatment. — In this form reduction is easy, but it is 
often difficult to keep the fragments in position. Several 
turns of a roller bandage are applied in such a way as to 
elevate the arm and at the same time press the clavicle 
downward. Elastic bandages or percutaneous suture of 
the ligaments may be necessary (Baum). 

2. SCAPULA 

Fractures of the scapula are rare (about 1 ^ ), and pre- 
sent several varieties. 

Fractures of the body and spine of the scapula are 
produced by direct violence ; the line of fracture may be 
multiple or stellate, but the fragments show little tendency 
to displacement. Crepitus and abnormal mobility may 
often be elicited, especially if the arm is put in an appro- 
priate position. The treatment consists in placing the arm 
at rest and applying a bandage with slight pressure. 



138 



FRACTURES AND DISLOCATIONS. 



PLATE 26. 

Fractures of the Scapula.— Fig. 1.— Specimen of fracture of the 
neck of the scapula. The fragment comprising the articular cavity 
and the coracoid process is depressed. 

Fig. 1 a.— The same in the living subject. The prominence of the 
-acromion is recognized ; the shoulder is somewhat depressed. (Au- 
thor's observation. ) 

Figs. 2 and 2 a -Specimen of multiple fracture of the body and 
spine of the scapula. The lines of fracture are united by callus. 
(Author's collection.) 



Fractures of the neck of the scapula are extremely 
rare and occur only at the so-called surgical neck ; I e., 
in such a way that the coracoid process remains attached 
to the articular fragment. In other words, the line of 
fracture runs from the notch of the scapula downward (see 

Plate 26). The differential 
diagnosis of fracture of the 
neck of the scapula is impor- 
tant, because it is apt to be con- 
founded with subcoracoid dis- 
location of the humerus. 

The symptoms of the fracture 
are : depression and some de- 
gree of abduction of the arm 
with prominence of the acro- 
mion ; if the arm is raised, 
crepitus is elicited and the de- 
formity disappears, but returns 
as soon as the support is remov- 
ed from the arm. Sometimes 
the edge of the fractured surface of the scapula can be felt 
through the axilla. The fracture unites readily if the ban- 
dage is applied in such a way as to place the arm and the 
scapula at rest. The indications are to keep the arm per- 
manently elevated, abducted, and in a slightly posterior 
position.* An axillary pad should be used. 

Fracture of the edge of the articular surface, espe- 




Fig. 46. — Fracture at the 
lower border of the articular 
surface. 



Tab. 26. 






Fig. 2 



Fiff^c 



FRACTURES OF THE UPPER EXTREMITY. 139 

eiallv the lower border, is rare ; being an intra-articular 
injury, it can be recognized only when the arm is placed 
in a certain position. The symptoms are, slight depression 
of the head of the humerus when the arm is held out at 
right angles to the side of the body ; and, sometimes, 
crepitus when the head of the humerus is made to move 
from before backward. 

Isolated fracture of the coracoid process by direct 
violence is extremely rare. A similar fracture of the 
acromion is somewhat more frequent, and is recognized 
by direct palpation and by the presence of abnormal 
mobility and crepitus. Sometimes the crack in the bone 
can be felt in marked adduction of the arm. Union may 
be obtained by slightly elevating the arm and placing it 
at rest. 

3. SHOULDER= JOINT 

Dislocation of the shoulder-joint is one of the most 
important, as it is one of the most frequent, injuries. Al- 
though its recognition presents no peculiar difficulties, 
many cases are overlooked. In a normal shoulder we can 
easily feel the acromion at the outer extremity of the spine 
of the scapula and its connection with the clavicle ; the 
coracoid process ; and the head of the humerus beneath 
the deltoid muscle. The head of the humerus is so plainly 
felt that, by rotating the arm, even the tuberosities and 
the groove between them can be made out. Through the 
axilla the head of the humerus and the edge of the glenoid 
fossa are felt. As we all know, contact in this very mov- 
able joint is not maintained by the capsule and ligaments, 
but by the muscles and atmospheric pressure. In paraly- 
sis of the deltoid muscle the head of the humerus is always 
somewhat depressed ; and there are cases of idiopathic 
palsy in children in which the soft parts are so thin that 
the downward displacement of the head of the humerus is 
visible. 

(a) Forward dislocation of the humerus (preglen- 



140 FRACTURES AND DISLOCATIONS. 

PLATE 27. 
Subcoracoid Dislocation of the Humerus.— The patient, a man 
of sixty -four, was injured about three weeks before the skiagraph was 
taken. In the interim the swelling subsided, so that the relations at 
the shoulder-joint are easily recognized. The prominence of the acro- 
mion is almost angular. The arm is abducted and the outer boundary 
forms an obtuse angle with the vertex directed inward. The long 
axis of the humerus is directed toward the coracoid process instead of 
toward the acromion, and underneath the coracoid process is an ill- 
defined prominence; the arm appears to be lengthened. The diagnosis 
of subcoracoid dislocation is unmistakable. 



oidal, also called subcoracoid, or subclavicular, depending 
on whether the head of the bone is found under the cora- 
coid process or under the clavicle). This is the most fre- 
quent dislocation at the shoulder-joint. It can be pro- 
duced artificially without difficulty by placing the cadaver 
in the dorsal position, abducting and elevating the arm to 
its full extent, and gradually forcing it backward. During 
this procedure the anterior portion of the capsule (the 
thinnest portion) is greatly stretched by the head of the 
humerus, and a tear is produced. The head escapes 
through the rent in front and below the coracoid process 
— the dislocation is complete. As soon as the arm is 
replaced in a more normal position, all the objective symp- 
toms of this luxation, except the ecchymosis, make their 
appearance. 

In the living subject subcoracoid dislocation is produced 
sometimes directly by a blow on the humerus from behind, 
or from the side; or, more frequently, indirectly by a fall on 
the side while the arm is elevated and abducted, or by a 
fall on the outstretched hand, or on the elbow, especially 
when the arm is directed backward. The accident has 
also been observed after violent movements of the arm, 
as in throwing. When the dislocation is produced by indi- 
rect violence, — that is, by excessive abduction, — the mech- 
anism is as follows : the humerus comes in contact laterally 



Tab. 27. 




^Cf\: 






) 



Lith.Anst F; Heichhold, Munclicn . 



FBACTUEES OF THE UPPER EXTEE3IITY. 



141 




with the scapula ; the region corresponding to the tuber- 
osities and the surgical neck (if the force continues to act) 
are pressed against the upper border of the glenoid fossa and 
the acromion. These 
constitute a fulcrum, 
and the short arm 
of the lever — i. e., the 
head of the humerus — 
is pried out of its nor- 
mal position, tearing 
the capsule. A dislo- 
cation produced in this 
way generally presents 
the character of a 
downward or infra- 
glenoid dislocation, 
which by a secondary 
displacement of the 
humerus under the ac- 
tion of the muscles is 
converted into a sub- 
coracoid dislocation. 
As regards the ana- 
tomic relations in a 
subcoracoid disloca- 
tion, the head of the 
humerus is found in 
close contact with the 
edge of the glenoid 

cavity, between it and the thorax (see Fig. 47), and may 
exert pressure on the large vessels and nerves. 

The symptoms of a typical subcoracoid luxation are 
very characteristic (see Plate 27). They are due to the 
fact that the head of the humerus is absent from its nor- 
mal position and occupies an abnormal position. The 
examination is always begun by inspection, as this alone 
often suffices for the diagnosis, palpation being desirable 



Fig. 47. — Horizontal section through 
the shoulder region and adjacent half of 
the thorax in a subcoracoid dislocation 
of the shoulder on the right side. The 
abnormal position of the head of the 
humerus and of the shoulder is indicated 
by solid lines, the normal position of 
these parts by dotted lines. The cross- 
section of the vessels and nerves is also 
shown. The tuberosities and the groove 
between them can be recognized on the 
head of the humerus. (After Anger. ) 



142 FRACTURES AND DISLOCATIONS. 

PLATE 28. 

Subcoracoid Dislocation of the Humerus ; Anatomic Speci= 
men.— Fig. 1.— From the skeleton, showing the abnormal position of 
the head of the humerus. What is seen more particularly is that the 
head occupies a lower position than normal, explaining the " lengthen- 
ing " of the dislocated arm. 

Fig. 2. —Muscle preparation. The characteristic position is also recog- 
nized, the angular prominence of the acromion and the deltoid muscle 
are particularly well shown; the latter is tightly drawn downward 
and meets the humerus at an acute angle. The characteristic outline 
of the dislocation is seen to be produced by the outer border of the dis- 
located humerus (lower half) and the edge of the deltoid muscle. The 
illustration shows, in addition to the deltoid muscle, the pectoralis 
major, the biceps, alongside of the latter a section of the brachials 
anticus, and a portion of the triceps. 



only as a confirmatory procedure. It is best to have the 
patient sitting on a chair with the back unsupported. The 
clothing should be removed down to the waist so as to 
enable the surgeon, who sits opposite, to inspect and com- 
pare both sides. This is best done by placing the sound 
arm in approximately the same position as that of the 
injured arm. 

The rotundity of the shoulder has disappeared and the 
acromion forms an angular prominence. The normal 
rotundity of the shoulder is formed by the head of the 
humerus and the deltoid muscle. If the latter is very 
atrophic, the acromion projects ; and if the head of the 
humerus is in an abnormal position, the acromion forms an 
angular prominence, even when the deltoid is well devel- 
oped, and in spite of the presence of considerable extrava- 
sation. That the prominence is due to the acromion is 
readily determined by following the course of the spine of 
the scapula, which ends in the acromion. 

In the region of the coracoid process and beneath it 
there is an abnormal prominence which is both visible and 
palpable, the latter especially when the humerus is rotated 
slightly backward and forward. This maneuver proves 



Tah.28. 







Fig.S. 




Fiq.l. 



Litfi.Ai%st.E Reixhlwi 



FRACTURES OF THE UPPER EXTEE3IITY. 



143 



that the prominence belongs to the humerus, and by its 
spherical form it is recognized as the head of that bone. 

The arm is in abduction, and immediately returns 
to that position when the reducing force is removed ; i. <?., 
by the exertion of a moderate force it can be adducted 
until it comes in contact with the thorax, but as soon 
as the pressure is removed, it immediately returns to an 
abducted position. This 
position is due to the ten- 
sion of certain ligaments 
— the coraco-humeral 
ligaments and the liga- 
ments attached to the 
tuberosities. 

The long axis of the 
humerus is directed to- 
ward the coracoid process 
or toward a point below 
the clavicle, instead of 
toward the acromion, as 
under normal conditions. 
This is readily deter- 
mined by comparing the 
injured with the sound 
side. 

The outer border of the 
upper arm appears bent 
and forms an angle with 
the vertex directed in- 
ward, whereas the sound arm presents an almost rectilinear 
border. This abnormality is caused by the arm being in 
abduction, producing the lower half of the line, and by 
the stretching of the fibers of the deltoid between the 
acromion and the humerus, representing the upper seg- 
ment (or upper side of the angle) of this broken line. 

The humerus appears to be lengthened and the distance 
between the acromion and a point on the elbow, such as 




Fig. 48. — Showing a young man 
with a subcoracoid dislocation of 
the humerus on the right side. 
The long axis of the humerus is 
indicated on both sides by solid 
lines. 



144 FRACTURES AND DISLOCATIONS. 

PLATE 29. 
Subcoracoid Dislocation of the Humerus; Anatomic Prep= 
aration. — This illustration represents a later stage in the dissection 
of the specimen shown in the preceding plate. The deltoid muscle has 
been separated from the clavicle and reflected outward so that the dis- 
tended acromial portion of the muscle is seen from within. The pec- 
toralis major has also been separated at its upper border and hangs 
down, supported by its costo-sternal origin and its insertion in the 
humerus. The pectoralis minor has been divided at the coracoid pro- 
cess and lies against the inner surface of the greater pectoral. The 
coracoid process is readily recognized by the two short muscular inser- 
tions, that of the pectoralis minor on the inner side and that of the 
coraco-brachialis, with the short head of the biceps, on the outer side. 
The coraco-acromial ligament runs from the coracoid process outward 
to the acromion. Underneath the coracoid process is seen the head of 
the humerus, and a little nearer the median line we see the cartilagi- 
nous articulating surface through a rent in the capsule. The muscles 
inserted on the tuberosities are also discernible on the median side, 
as is also the subscapular muscle inserted on the lesser tuberosity. 
Between the two tuberosities the long tendon of the biceps comes into 
view as it crosses downward in the direction of the belly of the biceps 
muscle, which has been completely dissected out (below the insertion 
of the pectoralis major). Between the wall of the thorax, of which 
the second, third, and fourth ribs are visible, and the humerus lies the 
brachial plexus, which obviously is exposed to injury by the head of 
the humerus in this dislocation. Between the humerus and the edge 
of the deltoid muscle is an empty space from which the adipose and 
connective tissue have been removed. This space, under normal condi- 
tions, is of course filled by the humerus. The circumflex nerve, 
which supplies the deltoid muscle, is seen crossing this space in an 
oblique direction from the plexus. 

the external condyle of the humerus, is actually length- 
ened in many cases — certainly never shortened. This can 
also be seen when the patient is inspected from behind. 
The explanation of this lengthening is readily seen when 
the dislocation is produced in the skeleton ; the head of 
the humerus being actually found at a somewhat lower 
point than its normal position in the articular cavity. 



Tab.20. 




1 ' 



Lith.Atist E Reichhold, Munchen . 



FRACTURES OF THE UPPER EXTREMITY. 



145 



Finally, the head of the humerus can be palpated more 
or less distinctly in its abnormal position through the 

Figs. 49-52. — Illustrating the differential diagnosis of subcoracoid 
dislocation of the humerus. In the figures a stands for acromion. 





Fig. 49. — Upward dislocation of Fig. 50. — Typical subcoracoid dis- 
the acromial end of the clavicle. location of the humerus. 



a -~ 





Fig. 51. — Fracture of the neck Fig. 52. — Fracture of the neck 

of the scapula. May be combined of the humerus with the arm in 

with sinking of the shoulder if abduction, 
the deltoid is paralyzed. 



axilla. Passive movement is exceedingly painful and 
limited ; active movements are even more restricted. 
10 



146 FRACTURES AND DISLOCATIONS. 

Among the accessory injuries are separation of a plate 
of bone at the greater tuberosity; rarely injuries to 
the vessels; more frequently injuries to the nerves. The 
nerves in this dislocation are always exposed to great ten- 
sion ; sometimes they suffer from contusion by pressure of 
the head of the humerus or by being caught between it 
and the thorax (see Plate 29). The circumflex nerve, 
especially, is often injured ; hence it is well to test the del- 
toid muscle, which it supplies, immediately after reduc- 
tion, in order to avoid error in prognosis. 

From what has been said it follows that the diagnosis 
of this luxation is not, as a rule, difficult ; in the worst 
cases all doubts may be dissipated by an examination 
under anesthesia. Nevertheless it will be well to refer 
to the differential diagnosis. The conditions that are to 
be considered are : 

Contusion of the shoulder and distortion of the shoulder- 
joint; in these injuries there is no displacement. 

Supra-acromial dislocation of the clavicle; in this injury 
the angular prominence is produced by the acromial end 
of the clavicle and not by the acromion itself. The arm 
is abducted, and the normal rotundity of the shoulder is 
preserved. 

Fracture of the neck of the scapula (see Fig. 51). The 
acromion is prominent, the shoulder is depressed and dis- 
placed someAvhat forward and inward ; but the dislocation 
can be made to disappear by simply elevating the arm, 
crepitus being at the same time elicited. 

Paralysis of the deltoid muscle. This is followed by 
depression of the shoulder, but the deformity can at once 
be made to disappear by supporting the arm. The arm 
is not in abduction. 

Fracture of the acromion, with great displacement of the 
fragments; the anatomic relation between the acromion 
and the head of the humerus is unaltered. 

Fracture of the surgical neck of the humerus (see Fig. 
52) ; the rotundity of the shoulder is preserved even 



FRACTURES OF THE UP PEE EXTREMITY. 147 

when the lower fragment is displaced inward, and the arm 
rests in abduction. Abduction does not tend to return 
after reduction, and the arm is never lengthened ; on the 
contrary, shortening is present in almost every case. 

Treatment. — The dislocation must be reduced as early 
as possible. If the surgeon possesses some degree of skill, 
reduction can be effected without anesthesia, and the head 
mav sometimes be pushed back into place under the pre- 
tense of making an accurate examination. In other cases, 
however, this cannot be done, and anesthesia must be at 
once resorted to. Among the many methods of reduction 
which have been devised and carried out, we shall recom- 
mend the following : 

1. Moderate Abduction with Extension. — The patient is 
placed on his back. An assistant abducts the arm slightly 
and applies extension, while counterextension is main- 
tained by a broad strip of cloth passed around the thorax. 
At the same time the surgeon applies direct pressure to 
the outside of the head of the bone in the direction of the 
articular cavity. 

The well-known method of Cooper consists in making 
traction on the arm in the long axis of the body with the 
foot in the axilla, thus exerting direct pressure on the 
head of the bone. The surgeon should remove his shoe. 

Extension btj hyperabduction : The assistant sits behind 
the patient, who lies on the ground. The surgeon exerts 
direct pressure against the head of the bone through the ax- 
illa while the arm is being abducted. In this method several 
assistants may be employed, the patient lying on a table. 

2. Kocher's Method. — This consists in several distinct 
steps or positions which must be accurately carried out 
(see Plate 30). They are : 

I. Adduction of the arm, until it touches the trunk. 
II. Outward rotation, until the flexed forearm approxi- 
mately occupies the frontal plane ; great care is required 
to avoid producing a fracture. During this phase the head 
of the humerus is displaced outward, away from the cora- 



148 FRACTURES AND DISLOCATIONS. 

PLATE 30. 

Method of Reducing Subcoracoid Dislocation of the Hum= 
erus. — In this plate Kocher's method is represented anatomically in 
its various phases. The specimen shown on Plate 29 was used for the 
purpose, each step being at once photographed, after which the illus- 
trations here reproduced were copied from nature. 

Fig. 1. — Adduction of the arm until the region of the elbow comes 
in contact with the trunk, which is in a straight position (step I). No 
material change in the position of the head of the humerus is produced 
by this step. 

Fig. 2. — Outward rotation of the adducted arm by means of the 
forearm flexed at right angles (step II), until the forearm approxi- 
mately occupies the frontal plane of the body. The opening in the 
capsule is plainly visible ; the head has moved nearer the acromion 
and further away from the brachial plexus. 

Fig. 3. — Elevation of the arm held in adduction and outward rota- 
tion (step III); in other words, the arm is raised and directed forward. 
This partially reduces the dislocation. 

Fig. 4. — Inward rotation completing the act of reduction (step IV). 

coid process and toward the acromion. This is recognized 
in figure 2 of Plate 30, by the increased distance of the 
head of the humerus from the brachial plexus. 

III. The arm is held in adduction and outward rotation 
and pushed upward and slightly forward. The head of the 
humerus now begins to slip through the opening in the 
capsule and moves toward its normal position in the 
glenoid fossa. 

IV. Inward rotation : This completes the reduction. 
The movement must be performed gently and without jar, 
so that often the bone is not felt slipping back into position, 
and the fact that reduction has been successful is only de- 
termined afterward by examination. 

By this method more than by any other the dislocation 
can often be reduced without anesthesia and with a mini- 
mum amount of injury to the parts. By adducting the 
arm the upper wall of the capsule is stretched and the 
head firmly held at the edge of the glenoid fossa, so that, 



Tab.30. 



X 








Fig.l. 



Fig, 2. 





FigJ. 



Hj 



Fig. 4-. 

Lith.Anst E Reichhold '. Munr/wn . 



FRACTURES OF THE UPPER EXTREMITY. 149 

when the arm is rotated, the edge of the cavity acts as* a 
fulcrum and the bone does not rotate about its own axis. 
The subsequent elevation has for its object to relax the 
coraco-humeral ligament. 

Reduction is recognized by more or less distinctly feel- 
ing the head slip into place, and especially by observing 
that the normal mobility and outline have been restored. 

[The results of reduction of recent dislocation of the 
shoulder by Kocher's method of manipulation when prop- 
erly performed are marvelous. The manipulation, how- 
ever, is frequently misunderstood and often misquoted in 
text-books. The most frequent mistake is to hold the arm 
in abduction during the external rotation rather than ad- 
duction. This improper position is illustrated in Treves' 
recent " System of Surgery." It is incorrectly translated 
in the American edition of Tillmann's " Surgery." Kocher's 
publication appeared in 1870. l The outward rotation, 
however, seems to be the most important part of the man- 
ipulation. Reduction seems to have been accomplished 
in many cases with the arm held away from the body (ab- 
duction) instead of against the chest (adduction). Theo- 
retically, adduction is the proper position, and practically, 
in my own experience, the better position. In a recent 
case I failed to reduce the dislocation with outward rotation 
and abduction, but at the second trial succeeded without 
any force with outward rotation and adduction. Great 
force is not necessary in this manipulation. — Ed.] 

In the after-treatment the arm must be fixed to the body 
with the hand of the injured side on the sound shoulder, 
handkerchiefs, roller bandages, or adhesive strips being 
used. After a week, passive movements should be begun, 
and a little later supplemented by active movements. The 
entire duration of the treatment, from the time of the in- 
jury until the patient is able to return to his duties, com- 
prises about four to five weeks. 

1 Berliner klin. Wochenschr. , 1870, No. 9, and Volkmann's Samm- 
lung klin. Vortrage, No. 83, p. 611. 



150 FRACTURES AND DISLOCATIONS. 

PLATE 31. 

Old Subcoracoid Dislocations with the Formation of a 
New Articular Surface on the Scapula, and Wearing Away 
of the Humerus. (Compare Fig. 44, p. 134). 

Fig. 1. — Anterior view of the two bones in dislocation. The head 
of the humerus conceals the region of the glenoid fossa, as it lies in 
apposition with the anterior surface of the neck of the scapula below 
the coracoid process. We see the free anterior surface of the head of 
the humerus covered with cartilage, and the edge of the callus-forma- 
tion on the neck of the scapula which surrounds the new articular sur- 
face. The humerus is slightly abducted. The amount of movement 
afforded by this abnormal joint is extremely limited, the reason of 
which is readily understood after a careful inspection of the bones 
where they come in contact with one another. 

Fig. 2. — Anterior view of the scapula as in figure 1. The humerus 
has been rotated through about 180 degrees, bringing into view its pos- 
terior surface, which is turned toward the scapula. On the scapula 
we see the glenoid fossa from the side, hence it appears greatly short- 
ened. Its anterior border is much diminished by the wearing away of 
the bone, and is joined at this point by the new articular surface, sur- 
rounded by a somewhat irregular wall of bone. The humerus also shows 
a depression, due to attrition with the edge of the glenoid fossa ; and, at 
the anatomic neck, an overgrowth of bone like that which is charac- 
teristic of arthritis deformans. Unfortunately, the eburnations that are 
found at the points of contact of the two bones where they have been 
rubbed together could not well be represented. (Author's prepa- 
ration. ) 

If it should be found impossible to effect reduction, an- 
other attempt should be made under full anesthesia, after 
enlarging the capsular opening by free movement of the 
arm. If even under anesthesia the attempt does not 
prove successful, and the dislocations cannot be reduced 
even with assistance, surgical interference must be 
resorted to in order to restore the normal relations of 
the parts as early as possible. The operation is readily 
performed through an incision from the coracoid process 
downward. 

[The usual mistake made in the attempt at reduction of 



Tab.31. 






\\ ^Hl 5 



V Fig. 2. ^j 




ZtfA. .4/w/: A 7 Retchhold, Munchen . 



FRACTURES OF THE UPPER EXTREMITY. 



151 



a dislocation is too great force and the repetition of manip- 
ulations. In the majority of instances reduction should 
not be attempted without anesthesia. This attempt should 
be made in only those few dislocations ay Inch experience 
has taught us can be reduced by simple manipulation with- 
out great force, as in Kocher's method for shoulder dis- 
location. When the proper 
methods have been carefully 
tried without reduction under 
anesthesia, the probabilities are 
that there is some obstacle ; 
and in such an event further 
and more forcible attempts at 
reduction only increase the dan- 
ger of injury. The surgeon 
should immediately expose the 
dislocation by an open incision, 
when in the majority of in- 
stances the obstacle can be re- 
moved and the bone easily re- 
placed. — Ed.] 

If reduction is neglected, 
there usually results a very 
serious condition known as an 
" old luxation" It is rare that 
a new joint with any degree of Fig. 53.— Simple dressing, 

mobility is formed ; as a rule, by means of a gauze bandage 
the shoulder-joint continues to stuffed with cotton, that may 
cause the patient pain, and be usecl after reduction of a 
movement is reduced to a mini- dislocati ™ of the humerus, 
mum. But even in these cases 

a surgical operation effecting reduction after removal of ob- 
structions or resection of the head of the humerus may be 
followed by considerable improvement. [As discussed on 
page 147, resection of the head of the humerus as a rule 
gives a much more serviceable arm than reduction of an 
old dislocation. — Ed.] 




152 FRACTURES AND DISLOCATIONS. 

In rare cases habitual luxation results ; the only success- 
ful method of treating it is a surgical operation consisting 
in resecting portions of the capsule for the purpose of 
shortening it. 

Modifications and Complications of Preglenoid Dis= 
location. — If the head of the humerus escapes from the 
glenoid fossa in a direct line forward, it sometimes lies so 
close to the fossa, between the scapula and the subscapular 
muscle, that the articular surface of the head still remains 
in relation with the edge of the glenoid fossa. In these 
cases, which are produced chiefly by direct violence, a 
groove is formed in both bones by attrition within a few 
weeks. In old cases of this kind the wearing away may 
be very considerable, forming a deep groove on the head 
of the humerus and completely wearing away the an- 
terior half of the glenoid fossa. At the same time the 
usual periosteal proliferation takes place, forming a kind 
of new joint for the head in its abnormal position (see 
Plate 31). Reduction in such cases is, as a rule, ex- 
tremely difficult, and often impossible without arthrotomy. 

Supracoracoid dislocations are extremely rare, and always 
combined with fracture of the coracoid process. 

Dislocation with simidtaneous fracture of the neck of the 
humerus: This constitutes a very grave injury. If the 
attempts at reduction by abduction and extension, supple- 
mented by direct manipulations, fail even under full anes- 
thesia, arthrotomy is indicated for the purpose of forcing 
the bones into place, or, if necessary, removing the frag- 
ment, especially if it is small and principally intra-artic- 
ular. The treatment formerly recommended was to aim 
at producing a false joint at the seat of fracture with- 
out attempting to correct the position of the head of the 
bone. [Without much doubt, in this injury the seat of 
fracture should be explored by an open incision, and if 
the fragment cannot be properly fixed with a fair hope 
of its union with good function of the joint, the head of 
the bone should be removed. — Ed.] 



FRACTURES OF THE UPPER EXTREMITY. 



153 



(b) Downward or subglenoid dislocation of the 
humerus (luxatio infraglenoidalis or axillaris). In this 
[rare. — Ed.] dislocation the head is often found at the lower 
border of the glenoid fossa, and is accordingly felt through 
the axilla. The appearance of the patient is most char- 
acteristic when he stands with his hands extended from 
the body, as in this position the line of the shoulder re- 
sembles a bayonet in shape. In this variety also there 
are : prominence of 
the acromion ; ab- 
sence of the head 
from the glenoid 
fossa ; and func- 
tional disturbances. 
Sometimes the arm 
is elevated (luxatio 
erecta), or in hori- 
zontal extension. 
Reduction is effect- 
ed by extension and 
direct pressure 
against the head 
through the axilla, 
with the thumb 
pressed against the 
acromion. 

(c) Backward or subacromial dislocation of the 
humerus (luxatio retroglenoidalis, subacromialis, infraspin- 
ata). This form is rarely met with and is mostly pro- 
duced by direct violence. The head is readily seen and 
felt in its abnormal position. The coracoid process forms 
a distinct prominence. Reduction is effected by extension, 
with the arm in abduction, and by direct pressure. 




Fig. 54. — Horizontal section through the 
shoulder-joint and adjacent half of the 
thorax in retroglenoid dislocation. (Com- 
pare Fig. 47, p. 141, after Anger. ) 



154 FRACTURES AND DISLOCATIONS. 

PLATE 32. 
Fracture of the Surgical Neck of the Humerus, with 
Marked Displacement of the Fragments and Abduction of 
the Arm. 

Fig. 1. — The specimen represents the anatomic conditions most 
faithfully. We see the head of the humerus with its tuberosities in 
the normal position. The end of the lower fragment is displaced in- 
ward as in a subcoracoid luxation. The possibility of injury to the 
plexus and the large vessels, and the strain and displacement of the 
tendon of the biceps, are seen at a glance. Above and medial to the 
head of the humerus is the coracoid process, where the short head of 
the biceps has its origin; the pectoralis minor has been removed. 
Above the coracoid process we see the clavicle, the outer extremity of 
which articulates with the acromion. Parts of the deltoid and pecto- 
ralis major muscles have been removed; the latter has been pushed out 
of the way so that the second, third, and fourth ribs are exposed. 

Fig. 2. — Upper extremity of the humerus, from the right side, 
showing a united fracture. Anterior view. The fracture included 
not only the surgical neck, but also the region of the tuberosities and 
the anatomic neck. There is great inward and upward displacement 
of the lower fragment; the arm is in abduction. The two fragments 
are united by an abundant mass of not very condensed callus. The 
fracture was evidently produced by great violence; it presents the 
appearance of a compression-fracture. (Author's collection.) 



4. HUMERUS 

(A) Fractures of the Upper End of the Humerus 
The upper extremity of the humerus presents the fol- 
lowing parts : the anatomic neck ; the region of the tuber- 
osities ; and, below the latter, the surgical neck. Fracture 
may take place in any one of these regions ; as a rule, the 
line of fracture is not confined to one, but extends more 
or less into neighboring parts. 

Fracture of the upper end of the humerus may be due 
to direct or to indirect violence. Indirect violence may 
produce it by compressing the bone in its long axis against 
the glenoid fossa or the arch of the acromion, as in a fall 



Tab.32, 




Fig.Z. 

l.ith. Ami F. Rpwiiiiold . Uunchm . 



FRACTURES OF TEE UPPER EXTREMITY. 



155 



Fractura- colli anatomiei 



Fr. through the 
tuberosities 



xr. Colli chirurgici. - -h 



on the elbow. Direct violence may consist in a blow or a 
fall on the outer side of the shoulder. 

Examination in these cases always presents some diffi- 
culties;, and if the extravasation of blood is profuse, the 
diagnosis may be exceedingly difficult. After inspection, 
by which we determine the direction of the shaft of the 
bone and the alteration in the outline of the shoulder, we 
proceed to palpation, which is equally important. The 
tuberosities, the groove between them, and the region of 
the surgical neck can 
be directly palpated 
under normal condi- 
tions ; not so, how- 
ever, the region of 
the anatomic neck 
and head of the bone. 
The parts should be 
felt from the outside ; 
from in front ; if 
necessary, from be- 
hind ; and last, but 
not least, through the 
axilla. 

(a) Fracture of 
the anatomic neck 
alone is a very rare 

accident. If only the articular head with its articular 
cartilage should break off, — in other words, a purely in- 
tracapsular fracture, — the vitality of the fragment would 
probably be endangered. It would act like any fragment 
consisting of bone and cartilage, as, for example, in the 
knee-joint. As a rule, however, the fracture is not alto- 
gether intracapsular ; the fragment is attached by portions 
of the capsule which convey the blood-supply, and the line 
of fracture includes neighboring portions of the tuberos- 
ities, of the shaft, or of the head. 

The injury is produced by severe external violence to 




Fig. 55. — Upper extremity of the hu- 
merus, showing the possible lines of frac- 
ture. 



156 FRACTURES AND DISLOCATIONS. 

PLATE 33. 

Fractures of the Upper End of the Humerus.— Fig. 1. — Nor- 
mal specimen showing the course of the epiphyseal line in a frontal 
section. 

Fig. 2. — Specimen showing fracture of the surgical neck with typi- 
cal displacement. Right shoulder-joint seen partly from the side and 
partly from behind. The displacement of the humerus forward and 
inward is recognized. 

Fig. 3. — Specimen of a united fracture of the left humerus. Ante- 
rior view. On the outer side, the line of fracture runs through and 
below the tuberosities and then curves inward toward the anatomic 
neck. The upper fragment (articular process) is in abduction, the 
lower fragment in adduction. The direction of the humerus in the 
region of the tuberosities can be recognized in spite of the abundant 
callus-formation, which is particularly marked in the diaphyseal por- 
tion. Owing to the displacement of the fragments, the base of the 
articular surface is in relation with the seat of fracture, which was 
probably impacted, and forms a right angle with the long axis of the 
humerus. (Path.-Anat. Inst., Greifswald. ) 

Fig. 4. — Lateral view of a man with a fracture of the surgical neck. 
Typical displacement of the shaft of the humerus forward and inward, 
so that the alteration in the direction of the axis is at once perceptible 
by comparing it with a normal arm (Fig. 4 a). (The patient's name 
was J. Wendigorra, twenty-two years of age. July, 1895.) 



the outside of the shoulder or by compression of the hum- 
erus in its long axis. The fragment from the head may 
be firmly impacted between the tuberosities or in the space 
above the lower fragment. The deformity is often very 
slight ; but sometimes the head has been found completely 
turned around, so that the broken surface presented toward 
the glenoid fossa, and the cartilaginous surface toward the 
upper end of the shaft of the humerus. 

The symptoms are those of a severe intra-articular 
injury. Direct palpation of the seat of fracture is out of 
the question, even under anesthesia ; all that can be deter- 
mined is that a fracture above the tuberosities exists. 
Abnormal mobility of the upper end of the humerus and 



Tab. 33. 




-> 



I 




Ficj/j. 



/ Fry. - • 




%1. 




A 




Fi 9 .4r\ 




j 



Fig. 4 . 

Lith . Anst F. Reichlioid . Munch, en . 



FRACTURES OF THE UPPER EXTREMITY. 



157 



crepitation, especially during rotation, are observed. There 
is marked functional disturbance, and pain is elicited by 
compressing the bone in its long axis. 

Treatment. — Rest in bed with extension by means of 
weights ; pad in the axilla ; movements should be begun 
early. [In two cases which I have observed and diag- 
nosed as fracture of the anatomic neck, this method of 
treatment by extension was most satisfactory. — Ed.] 

(b) Fracture of the Surgical Neck (Plate 32, Fig. 2). 
— This is quite common. The line of fracture is below 
the tuberosities or may 
even include them. 
The upper fragment is 
therefore partly under 
the influence of the 
muscles which are in- 
serted in the tuberosi- 
ties. The fracture oc- 
curs usually in older 
individuals and is pro- 
duced by direct vio- 
lence, as by fall on the 
shoulder ; or indirect 
violence by a fall on 
the hand or elbow. 
The fragments may 

become impacted or they may unite with marked de- 
formity. 

The following considerations are of prime importance 
both for a clear conception of the mechanism and for the 
treatment of these fractures : The upper end of the shaft 
of the humerus may be displaced inward or outward at the 
seat of fracture. If it is displaced inward, the arm is in 
abduction, but does not tend to return when the reducing 
force is removed ; the long axis of the humerus points 
toward the coracoid process or the clavicle. If the shaft 
is displaced outward, the arm is in adduction. This posi- 




Fig. 56. — Axillary pad, held in place by 
a short bandage to prevent slipping. 



158 



FRACTURES AND DISLOCATIONS. 



tion of adduction is rare, and is usually produced by indi- 
rect force. The abduction — L e., inward displacement of 
the end of the shaft at the seat of fracture — is much more 
frequent, and is produced, as a rule, by the continued 
action of the injuring force in a fall- on the outer and 
posterior portions of the shoulder (compare Figs. 57 and 
58). 

Symptoms. — In palpating the lateral outline of the 
shoulder the convexity of the head of the humerus is felt 




Fig. 57. — Fracture of the sur- 
gical neck. The upper end of the 
loAver fragment is displaced in- 
ward. The arm is in abduction. 




Fig. 58. — Fracture of the sur- 
gical neck. The upper end of the 
shaft is displaced outward and 
wedged into the bone; hence the 
arm is in adduction. 



in its normal position under the acromion. The injured 
arm is either in abduction or in adduction, but does not 
tend to return to its position after the reducing force is 
removed. In many cases there is shortening of the arm, 
a point of distinction from subcoracoid luxation. As a 
rule, abnormal mobility may be detected if the head is 
firmly fixed and crepitation is elicited during rotation of 
the arm. Occasionally displacement of the upper end of 
the shaft forward, inward, and upward can be demon- 
strated. In such a case the fragment is forced into the 



FRACTURES OF THE UPPER EXTREMITY, 



159 



soft parts, especially into the pectoralis major muscle, and 
may even appear close under the skin (see Fig. 59). 
A case of this kind presents some similarity to sub- 
coracoid dislocation ; the diagnosis will be determined 
by the presence or 'absence of shortening and the other 
above-mentioned symptoms. Impaction of the fragments 




Fig. 59. — Fracture of the surgical neck. On the anterior surface of 
the right shoulder region the sharp end of the fractured shaft of the 
humerus is seen pushing against the skin. The arm is in abduction, 
but does not tend to return when reduced. There is also some shorten- 
ing. (The patient was a man, twenty years of age. ) The fragment 
was withdrawn from the soft parts and the fracture reduced under 
anesthesia. 1896. 



may complicate the diagnosis, but it should always be pos- 
sible to exclude a dislocation. The combination of frac- 
ture and dislocation has already been discussed. 

Treatment. — If there is distinct displacement of the 
fragments, they should be replaced with great care ; as a 
rule, an anesthetic is desirable. For the subsequent treat- 



160 



FRACTURES AND DISLOCATIONS. 



ment, fixation of the entire arm, including the shoulder 
(see Fig. 60), by means of splints and a pad in the axilla 
(see Fig. 56), will suffice if there is no tendency to secon- 
dary displacement of the fragments and the end of the shaft 
is displaced inward. If the end of the shaft is displaced 
outward, constituting the so-called adduction-fracture of 
Kocher, no axillary pad is used. If the fragments tend 
to become displaced, — as, for instance, in oblique fractures, 
— no attempt should be made to treat the case by the 
ambulatory method. The injury is then a severe one, and 




Fig. 60. — Showing a patient in bed with extension applied to the 
arm on a sliding hand-rest; connterextension across the breast and by 
lateral traction on the upper arm. 



fraught with great functional disturbance and possibly 
grave injury to surrounding parts. The proper treatment 
is rest in bed and permanent extension in the long axis of 
the arm by means of weights, with a pad in the axilla, or, 
better, an additional loop to effect counterextension. By 
this means the shoulder-joint is freely accessible and under 
constant supervision, so that even during the first few days 
massage can be resorted to and the weights temporarily 
removed for the purpose of performing gentle passive 
movements. After a time the extension apparatus may be 



FRACTURES OF THE UPPER EXTREMITY. 



161 



arranged so as to allow the patient to carry his forearm in 
a sling, the dressing being confined to the upper arm and 
the weight hanging free during the daytime when the 
patient is allowed to be out of bed (Fig. 62). At night 
the extension apparatus is again applied as usual over a 
pulley fixed to the foot of the bed (Fig. 61). 

(c) Fracture through the Tuberosities (Fractura 
pertubereularis, Kocher). — A transverse fracture of the 
humerus at the level of the tuberosities is produced, as a 
rule, by a blow 

or a fall on the 
outer side of the 
shoulder. The 
displacement is 
the same as in 
fracture of the 
surgical neck. 
Impaction has 
been observed. 
The treatment is 
based on the 
same principles 
as that of frac- 
ture of the sur- 
gical neck, tak- 
ing due account 
of the injury to 
the muscular insertions, which is apt to be severe. 

(d) Traumatic Epiphyseal Separation at the Upper 
End of the Humerus (Plates 33 and 34). — This injury, 
owing to its relative frequency, is of the greatest practical 
importance. It is, of course, only possible before ossifi- 
cation of the so-called epiphyseal cartilage, or, better, in- 
termediary cartilage, has taken place, — i. e., in young 
persons, — and is produced by a fall on the shoulder or the 
arm. To understand its mechanism it is necessary to 
know the anatomic details of the epiphyseal line (see Plate 

11 




Fig. 61. — Showing the patient in bed. Ex- 
tension with the elbow flexed; counterexten- 
sion across the chest. 



162 



FRACTURES AND DISLOCATIONS. 



33, Fig. 1, and Toldt, Anatomischer Atlas, Figs. 250- 
254). 

The symptoms are often qufce characteristic ; they point 
to a separation of the bone similar to that which occurs in 
fracture of the surgical neck. The outline of the shoul- 
der is preserved as the head of the bone is in its normal 

position. In moderate displace- 
ment abnormal mobility and 
crepitation may sometimes be 
made out below the upper frag- 
ment; when the patient is under 
anesthesia, the head can some- 
times be fixed firmly with the 
fingers. The crepitation is softer 
than that usually observed in frac- 
tures; it is the so-called cartilage 
crepitation. The displacement is 
frequently well marked, the dia- 
physeal extremity being displaced 
forward and inward and produc- 
ing a circumscribed, almost an- 
gular prominence, best seen by 
inspection from the side or from 
above, the surgeon standing be- 
hind the patient. The arm is 
therefore in abduction. Some 
rare cases present a displacement 
that is almost equivalent to dis- 
location of the end of the shaft 
inward and upward. In such a 
case reduction may be extremely difficult, if not impossible, 
even under anesthesia. If it is successful, the rest of the 
treatment is the same as for fracture of the surgical neck. 
If, however, reduction cannot be effected, the parts must be 
exposed by free incision, the line of separation cleared of 
interposed tissues, and the two parts forcibly brought into 
apposition. The author knows of a number of successful 




Fig. 62. — Extension ap- 
paratus for fracture of the 
humerus, to be worn during 
the day (compare Fig. 61). 



FRACTURES OF THE UPPER EXTREMITY. 



163 



cases in winch reduction was thus effected and the frag- 
ments kept permanently in position by inserting a long 
steel needle. 




Fig. 63. — Traumatic epiphyseal separation at the upper end of 
the humerus, with typical displacement of the diaphyseal fragment 
forward and inward. We see that the axis of the arm is directed 
toward a point considerably in advance of the prominence of the 
acromion. The patient, fifteen years of age, had fallen from a high 
stack of straw directly on the left shoulder, and was admitted to the 
clinic two weeks after the injury. Through an incision in front of the 
shoulder the completely dislocated diaphyseal extremity was replaced 
and fixed by means of a steel needle. Recovery with good function. 



Accurate reduction is necessary to save the youthful 
patient from a deformity and loss of function which 



164 FRACTURES AND DISLOCATIONS. 

PLATE 34. 

Traumatic Epiphyseal Separation at the Upper End of the 
Humerus. — Fig. 1. — Specimen of a juvenile shoulder-joint. The 
connection between the humeral epiphysis and the scapula is preserved 
by the capsule and ligaments and by the muscles that insert at the 
tuberosities. The diaphyseal segment is completely separated. A 
few tags of periosteum cling to the epiphysis. The union between 
the coracoid process and the scapula has not as yet become ossified. 

Fig. 2. — A young man with marked arrest of development of the 
right arm due to early traumatic lesion of the epiphyseal cartilage. 
The patient (Bertram, 1878) sustained an injury at the upper end of 
the humerus in early childhood. (Author's observation.) 



will be noticeable throughout life. Besides, if reduction 
has been incomplete after this injury, the development of 
the epiphyseal cartilage is retarded, the humerus fails to 
grow and remains shorter than that of the sound side 
(Plate 34, Fig. 2). 

An appropriate extension dressing, and particularly a 




Fig. 64. — Showing the same girl represented in figure 63, from 
above. We see the enlargement of the pectoral portion of the left 
shoulder region, due to the dislocation of the diaphysis. 

good axillary pad (Fig. 56), may be required to keep the 
parts in good position. 

In the new-born, epiphyseal separations sometimes re- 
sult from injuries sustained during delivery. The epiphy- 




Tab. 3*. 



Fig£. 



J.Uh. AnstJZReichhold, Munc/un. 



FRACTURES OF THE UPPER EXTREMITY. 



165 



sis (the head plus the tuberosities) occasionally shows 
marked outward rotation; the shaft is rotated inward, so 
that after union takes place the function is greatly inter- 
fered with. 

(e) Isolated Fracture of the 
Greater or Lesser Tuberosity. — 
Fracture, or splitting off, of the greater 
tuberosity is sometimes met with in con- 
nection with dislocation of the humerus. 
It may also be produced by rotation in 
violent efforts at reduction. Isolated 
fracture of the lesser tuberosity is much 
more rare. The symptoms are : pain 
on pressure, functional disturbance, 

and separation at the seat of fracture. 

.„. r , . , Fig. 65. — Eight 

The treatment consists in relaxing the humerag . gplitting 

muscles that have their origin at the [sprain fracture _ 

lesser tuberosity by appropriate move- £ D ] £ f t he 

ments, in prolonged rest, etc. greater tuberosity. 




(B) Fractures of the Shaft of the Humerus. 

(Plate 35.) 

These fractures are produced by direct or indirect vio- 
lence and present the general symptoms of fracture in a 
pronounced form : abnormal mobility, crepitation, and 
varying degrees of deformity. When the seat of fracture 
is below the insertion of the deltoid muscle, the upper frag- 
ment may be drawn upward and outw T ard (dislocatio ad 
axin). In fractures occupying the junction between the 
middle and lower thirds of the humerus the mnsculospiral 
nerve is often injured, either primarily at the time of in- 
jury, or secondarily by pressure of the callus in which it is 
often embedded. 

This complication should receive careful attention from 
the very outset. It is recognized by paralysis of the ex- 
tensor muscles of the hand, making it impossible to extend 



166 



FRACTURES AND DISLOCATIONS. 



Fig. 66. — Torsion-fracture of the humerus. Skiagraph. Hellmund, 
thirty-three years of age, sustained a fracture of the humerus by fall- 
ing on the arm in a wrestling bout. In addition to the fracture, there 
was paralysis of the musculospiral nerve (compare Fig. 79). As the 
paralysis was not improved by an extension bandage, such as shown 
in figure 60, the nerve was exposed by an incision over the seat of 
fracture, twelve days after the injury ; no injury of the nerve could, 
however, be detected. The wound was therefore closed, after inter- 
posing a soft pad, consisting of a layer of muscular tissue, between the 
nerve and the fragments, which were found in good position. The 
paralysis gradually disappeared, and the patient recovered with good 
functional result. [This observation of paralysis following a contusion 
of the nerve is a very interesting one, and the possibility should be 
borne in mind. Nevertheless it seems a safer plan to expose the 
nerve by incision if function is not restored in a few days. — Ed.] 



FRACTURES OF THE UPPER EXTREMITY. 



167 



the fingers. By this means a bad error in prognosis may 
be avoided. Injuries to the vessels are less frequent. 

TTith appropriate treatment good union takes place. 
Nevertheless the formation of a false joint is relatively 
more frequent after fractures of the humerus than after 
fractures of the other bones of the extremity, partly because 
of the greater difficulty of immobilizing the part, and partly 
on account of the displacement, which is often considerable, 
and may be complicated by the interposition of soft parts 
between the ends of the frag- 
ments. 

Treatment. — By incasing 
the upper arm, including the 
shoulder- and elbow-joints, in 
a circular bandage, the axil- 
lary space is protected against 
dangerous pressure. We may 
use plaster-of-Paris, wire, or 
padded tin splints. If the 
latter are used, a long splint 
should be applied to the outer 
side of the entire arm and a 
shorter one to the inner side 
of the upper arm. The wire 
splints may readily be applied 
in such a way as to exert per- 
manent traction in the long axis of the humerus. The 
splint is simply bent at the proper angle and firmly ban- 
daged to the forearm flexed at a right angle. The upper 
extremity is bent over in such a way as to leave a space 
above the shoulder. Then a short loop, well padded with 
cotton, is passed around the axilla and attached to the pro- 
jecting end of the splint with moderate tension, so as to 
produce permanent traction. The tension may be regu- 
lated by occasionally changing the length of the axillary 
loop. This dressing may be used in fractures of the upper, 
as well as of the lower, end of the humerus. A very ser- 




Fig. 67. — Simple splint- 
dressing with elastic traction 
for fracture of the humerus. 



168 FRACTURES AND DISLOCATIONS. 

PLATE 35. 

Fractures of the Humerus.— Fig. 1. — Anatomic preparation of 
the humeral region. Lateral view, showing the relation of the mus- 
culospiral nerve to the bone. The nerve lies directly upon the bone 
at the site of an artificial fracture. In front of it are recognized the 
brachialis anticus and the biceps ; behind, the triceps ; and above, the 
deltoid. The point where the nerve comes in contact with the bone 
corresponds approximately to the junction between the middle and 
lower thirds of the arm. 

Fig. 2. — United fracture of the shaft of the humerus, with moderate 
deformity. In this case the musculospiral might have been injured. 

Fig. 3. — Fracture of the lower end of the humerus above the con- 
dyles (supracondylar fracture), with typical deformity simulating a 
posterior dislocation of the forearm. (See Plate 38.) 



viceable appliance for all fractures of the humerus is the 
so-called collar-splint made of plaster-of-Paris strips, de- 
vised by Albers. The splint covers the entire outer and 
posterior side of the arm, which is flexed at the elbow with 
the forearm in supination, from the wrist to the shoulder, 
and extends up over the lateral and posterior region of 
the neck as far as the line of the hair. The plaster-of- 
Paris strips are applied directly to the skin, which has 
previously been well oiled. The plaster dressing is then 
covered with a soft roller bandage, and a well-fitting gutter 
is obtained, which assures complete fixation of the arm and 
shoulder region (Fig. 68). While the bandage is being 
applied, one assistant should hold the head while a second 
applies extension to the elbow. 

If there is much tendency to secondary displacement 
after the fracture has been correctly reduced, good perma- 
nent extension becomes necessary. The counterextension 
in that case may not be applied in the axilla ; or, when the 
fracture is to be treated with splints without rest in bed, 
the arm must be brought into greater abduction, so that 
the entire lateral surface of the thorax may be utilized for 
counterextension. 



TabJt 



I 





Fig.l. 






LUh. Ansi >'■ ReicJihold. Miinriicn . 



FRACTURES OF THE UPPER EXTREMITY. 



169 



It is a better plan in such cases to give up ambulatory 

treatment altogether and apply permanent extension to the 
forearm and lower part of the upper arm by means of 
weights and a sliding hand-rest. The arm may be slightly 
abducted and supported on a table of suitable height 
placed by the side of the bed. This has the advantage 
that a counterextending loop can be applied on the thor- 
acic portion of the ax- 
illa, thus avoiding dan- 
gerous pressure on the 
nerves and vessels in 
the axillary space. 
Heavier weights can 
thus be used on the 




extension apparatus, a 

distinct factor in ob- 
taining a good result. 

[Surgeons in this 
country prefer a much 
simpler dressing for 
fracture of the shaft in 
the humerus. 1 The 
forearm ? in a flexed 
(right angle) position, 
and a r m are first 
lightly bandaged. The 
arm from elbow to 
shoulder is then fixed 
with well-padded 
splints. The arm is then fixed to the chest with a pad in 
the axilla. This pad is very important. It should extend 
the full length of the arm to the elbow ; if too short, it will 
act as a fulcrum, and the lower fragment will be bent to- 
ward the side of the body. The dressing of this fracture 
with an anterior right-angled splint should be condemned. 

1 See Scudder, The Treatment of Fractures, W. B. Saunders & Co., 
1900. 



Fig. 68. — Albers' collar splint. 



PLATE 35 a. 
Explanation : Normal Elbow of an Adult as seen in the 
Skiagraph. [Note in the skiagraph the light shadow in the area of 
the fossa olecrani. This is normal, and should be remembered in the 
diagnosis of diseases of bone which diminish the density of the bone 
shadow. In this photograph the medial (inner) part of the lower end 
of the humerus shows much lighter than usual, also the shadow of the 
radius and ulna in the lower skiagraph. — Ed.] 



Humerus 



E/xicontfyUis medialis 



Olecranon, 
Trochlea humeri 




Anterior view. 



Fossa olecrani 
■EftLcondylus lateralis 

- Caytitukim, humeri 
CapXlulum radii 



Tiwerosilas radii 
Radios 



(b) Lateral view. 



Epicondylus media/is 
fossa otecrasu 



Olecranon/ 



Radius -> 




Tab. 35 a. 







FRACTURES OF THE UPPER EXTREMITY. 



171 



If a wire splint is employed, the method illustrated in fig- 
ure 67 is the best. — Ed.] 



(C) 



Fractures of the Lower End of the Humerus 



The segment of the bone with which we here have to 
deal extends upward as far as the insertion of the supina- 
tor longus. The revised anatomic nomenclature contains 
some changes which are indicated in the accompanying 
illustration (Fig. 70). 

The diagnosis of fractures of the lower end of the 
humerus is often exceeding- 
ly difficult. It demands a 
careful examination, especi- 
ally by palpation, and an 
accurate knowledge of the 
anatomy. 

The topography of the 
bony points under normal 
conditions is important, es- 
pecially the relation of the 
condyles to the tip of the 
olecranon. When the arm 
is in extension, a straight 
line connecting the condyles 
passes through the tip of 
the olecranon (Fig. 71). 
When the elbow is flexed 
at a right angle and the 
forearm is midway between 
pronation and supination, 
the three points form a tri- 
angle, the plane of which 
corresponds with the frontal 
plane of the body (Fig. 72). 

A knowledge of the normal conditions is supplemented 
in a special case by comparison with the sound side. This 




Fig. 69. — Modified triangular 
dressing of heavy lead strips with- 
out padding. (After Dr. Port. ) 



172 



FRACTURES AND DISLOCATIONS. 



is all the more important as individual variations are not 
infrequently met with. The Rontgen-ray examination of 
these fractures is not, as a rule, as valuable and decisive as 



fossa, radial, x . 



Mpicondyl. lat. — 




Capituium- 
hiLhteri. 



y> Fossa, eoroTtoiS* 



HpicondyL meet* 



Trochlea, 
huftterL 



Fig. 70. — Modern terms according to the revised nomenclature. 




Fig. 71. — The line connecting 
the condyles passes through the 
tip of the olecranon. 




Fig. 72. — The lines joining the 
condyles with the tip of the olec- 
ranon form a triangle. 



might be supposed a priori. If the method is resorted to 
at all, the sound side should always be photographed for 
purposes of comparison. 



FRACTURES OF. THE UPPER EXTREMITY. 



173 



Fractures of the lower end of the humerus do not lend 
themselves to classification. They present a great variety 
of forms which often merge one into the other. In every 
case, however, the fractures illustrated below must be dis- 
tinguished. 




e 

Fig. 73. Fig. 74. 

Figs. 73 and 74. — Various forms of fracture occurring in the lower 
end of the humerus: a-a, Supracondylar transverse fracture (Fig. 73); 
b-b, transverse fracture of the true articular process (Fig. 73) ; c-c, ob- 
lique external fracture (Fig. 74); d-d, oblique internal fracture (Fig. 
73); e-e, isolated fracture of the internal (medial) condyle (Fig. 74); 
/-/, isolated fracture of the external (lateral) condyle (Fig. 73); 
g-g, intra-articular splitting off of the capitellum (Fig. 74). Longi- 
tudinal and T, Y, and V fractures are produced by combinations of 
various lines of fracture. 



We shall now proceed to give a detailed description of 
these fractures : 

(a) Supracondylar Fracture (Fradura supracondy- 
lica). (Plate 35, Fig. 3.) — This fracture is usually pro- 
duced by a fall on the elbow or hand, and is a common 
fracture in children. The lower end of the humerus may 
be broken through the shaft by a movement of flexion 
anteriorly or posteriorly (hyperextension). Kocher 



ac- 



174 FRACTURES AND DISLOCATIONS. 

PLATE 36. 
Fractures of the Lower End of the Humerus.— Figs. 1 a and 

1 b. — Bones of the right arm of a child, severely injured by a machine 
accident. Figure 1 a shows the transverse fracture and a crack run- 
ning downward in the shaft of the humerus; also a partial separation 
of the lower epiphysis at its inner and middle portions. The bones of 
the forearm are shown in figure 1 b. The radius is normal; the ulna 
presents a longitudinal fracture which has produced separation of the 
olecranon. The arm had to be amputated. (Author's collection.) 

Fig. 2. — Longitudinal fracture of the humerus, extending into the 
elbow-joint. The specimen is the result of injury from a load of shot 
discharged at very short range. At its middle the bone was completely 
shattered ; the lower fragment presented the longitudinal fracture seen 
in the picture. The patient recovered after high amputation of the 
arm. (Author's collection.) 

Fig. 3. — Typical transverse fracture of the humerus above the con- 
dyles, with longitudinal fracture extending into the elbow- joint — so- 
called T-fracture. (Author's collection.) 

Fig. 4. — Oblique fracture through the articular extremity of the 
humerus splitting off the capitellum and external condyle. Oblique 
external fracture. (Author's collection.) 



cordingly distinguishes between flexion-fractures and ex- 
tension-fractures (Figs. 75 and 76). These two forms also 
present certain clinical differences, especially as regards 
the usual course of the line of fracture, the deformity, and 
the treatment. Extension-fractures so far as etiology is 
concerned, are analogous to posterior dislocation of the 
forearm. 

The articular fracture represented in the skiagraph 
(Fig. 77 — from a boy) belongs to the class of extension- 
fractures. 

Symptoms. — The deformity, as a rule, is typical. This 
is particularly true in supracondylar transverse fractures 
and in oblique fractures, classified by Kocher among the 
extension-fractures. The deformity suggests that seen in 
posterior dislocation of the forearm ; the lower fragment 
is displaced backward (Plate 35, Fig. 3 ; also Fig. 75) by 



Tab.36. 








Figlb 






Fig A, 



FigJ. 



JMh.AnM.t: Ht 



FBAOTUEES OF THE UPPER EXTREMITY. 175 

the action of the triceps muscle. An exception is formed 
by the other supracondylar oblique fractures, the flexion- 
fractures of Kocher (Fig. 76), in which the course of the 
line of fracture is such that posterior displacement of the 
lower end of the fragment is impossible. The sharp end 
of the shaft of the humerus in these fractures is displaced 
backward and sometimes enters the triceps muscle, whereas 
in the so-called extension-fractures it is displaced forward 
and may penetrate the brachialis anticus. 

An important step in the examination consists in seiz- 





Fig. 75. — Diagram of exten- Fig. 76. — Diagram of a flexion- 
sion-fracture (Kocher) ; the direc- fracture (Kocher); the direction 
tion of the line of fracture is from of the line of fracture is from be- 
behind and above, forward and fore and above, backward and 
downward. downward. 



ing the lower end of the humerus by the condylar promi- 
nences, which are readily felt, and attempting to elicit 
abnormal mobility with the shaft. A fracture at the lower 
end of the humerus may also be recognized by fixing the 
arm and pushing the forearm against it. If a fracture is 
present, crepitus and abnormal mobility will be discov- 
ered. The forearm also presents a certain mobility, both 
for abduction and for adduction. The position of the 
olecranon with respect to the condyles is normal ; not in- 



176 



FRACTURES AND DISLOCATIONS. 



frequently the fragments can be directly felt. Reduction 
is effected by simple extension with the elbow in flexion, 




Fig. 77. — Old, supracondylar extension-fracture, with the same de- 
formity as in dislocation. Skiagraph. 

Ludwig Maack, ten years old, was injured by a fall three months 
before admission. An obtuse-angled contracture of the joint, marked 
osteoplastic thickening at the lower end of the humerus, and paralysis 
of the musculospiral Avere present. The skiagraph shows the posterior 
displacement of the lower fragment ; the lower end of the diaphysis in- 
terferes with flexion. Operation: The musculospiral nerve was dissect- 
ed out and found to be completely divided, the two ends grown fast 
to the bone and cicatricial tissue; the nerve was repaired by a suture, 
and the lower end of the shaft of the humerus was removed, where- 
upon flexion at once became possible almost as much as in the normal 
limb. Result: Improved motion at the elbow after a long course of 
exercises ; the paralysis of the musculospiral nerve did not disappear. 



but the deformity tends to return when the extending 
force is removed. 



FRACTURES OF THE UPPER EXTRE31ITY. 



Ill 



Treatment. — Complete red net ion, if necessary under 
anesthesia, and fixation by means of splints or padded tin 
glitters applied to both the outer and the inner side of the 
limb. The arm is fixed with the elbow either in exten- 
sion or in flexion, in whichever position retention is most 
effectually obtained. In adults an adhesive plaster dress- 
ing with permanent extension by means of weights may 
be used. The arm is placed in extension with the fore- 
arm and hand on a sliding rest ; the hand should be ex- 
posed and in supination. Lateral loops or sandbags may 
be necessary to effect counterextension or pressure. In 
children a splint dressing is all that is necessary. The 







Fig. 78. — Extension dressing applied to the forearm in the treatment 
of a T-fracture. 



wire splints recommended for fractures of the shaft of the 
humerus and illustrated on page 167 may be used (see 
also Fig. 67, page 167). The importance of careful re- 
duction and constant supervision cannot be emphasized too 
strongly. I am in the habit of anesthetizing the children, 
not only at the first dressing, but in some cases also at 
subsequent dressings. The dressing should be changed at 
short intervals. Passive movements, massage, etc., must 
be begun early. Improper treatment may result in union 
with outward (varus) or inward (valgus) deformity of the 
limb (Plate 37). 

[The position of the forearm, flexion or extension, is a 
12 



178 



FRACTURES AND DISLOCAl^uNS. 



much disputed point. This subject of elbow fractures in 
children has recently been exhaustively studied and dis- 
cussed by Fred. J. Cotton, of Boston/ who concludes 
that in the majority of instances the position of acute 
flexion seems to have given the best results, although he 




Fig. 79.— Paralysis of the musculospiral after compound fracture of 
the lower end of the humerus. The scar is seen at the elbow (boy, 
eight years old). 

agrees with the majority of authors that the most impor- 
tant point in the treatment is proper reduction. Scudder 2 
recommends the position of acute flexion, although it may 
not be possible at the first or second dressing. The expe- 

1 Annals of Surgery, Feb. and Mar., 1902. 

2 The Treatment of Fractures, Saunders & Co., Phila., 1900. 



fbactVSes of the upper extremity. 179 

rience in the surgical clinic of the Johns Hopkins Hos- 
pital also favors this position. It is a much simpler 
method than the extension position. — Ed.] 

As regards accessory injuries, the ulnar nerve is more 
rarely involved than the musculospiral and median, 
which are sometimes completely divided; that these com- 
plications must be carefully, and as a rule at once, treated 
by operation needs no more than a passing reference. 
Injury to the blood-vessels indicated by beginning gan- 
grene of the arm has not infrequently occurred. 

(b) Transverse Fracture of the True Articular Pro- 
cess (Fractura processus cubitaMs s. articular is, Fractura 
diacondylica, see Fig. 73, page 173, line 6-6). — Here we 
have to deal with a transverse fracture below the condyles 
along the cartilaginous border ; L <?., a true intra-articular 
injury. In actual practice it is produced by a fall on the 
elbow or hand, the force of the blow being transmitted to 
the lower articular end of the humerus through the bones 
of the forearm. Experimentally it may be produced by 
compressing the bone from below in its longitudinal axis. 

This variety includes traumatic separation of the 
epiphysis at the lower end of the humerus, in which the 
line of separation takes the same direction (see Plate 41, 
Fig. 3, and Plate 36, Fig. 1 a; also text, Fig. 80). This 
articular fracture is most frequently observed in the form 
of an epiphyseal separation, in children and youthful indi- 
viduals. For the development of the centers of ossifica- 
tion in the epiphysis the reader is referred to an anatomic 
atlas (Toldtfs Atlas, Figs. 255-257). 

The symptoms are those of contusion of the joint with 
slight deformity ; some passive movement remains and is 
practically painless. By pushing the forearm forcibly 
against the arm pain is elicited. When the intercondylar 
line is fixed, there is still a certain degree of mobility at 
tha elbow-joint, both from before backward and from side 
to side, accompanied by slight crepitation (cracking). The 
examination must be made under anesthesia. 



180 



FRACTURES AND DISLOCATIONS. 



Treatment. — Reduction. Splints or extension dress- 
ing acting in the long axis of the humerus with the fore- 




Fig. 80. — Lower end of the humerus from a boy ten years of age; 
normal; skiagraph. A knowledge of the normal epiphyseal lines, as 
illustrated in this picture, is of the utmost importance to enable one to 
judge skiagraphs obtained from children. A mistaken diagnosis of 
fracture of the internal condyle and external oblique fracture is often 
made from the skiagraph, an error that could be avoided if the skia- 
graph were compared with the picture of the sound elbow. (Compare 
Plate 41, Fig. 3.) 



arm either in flexion or extension, 
should be begun early. 



Passive movements 



FRACTURES OF THE UPPER EXTREMITY. 181 

(c and d) Oblique Fractures of the Lower End of 
the Humerus. — In these oblique fractures either the outer 
or the inner portion of the articular extremity is split off. 
If, as happens in exceptional cases, both are fractured, the 
injury might be described as a double oblique fracture, or 
& fractura condi/Iica, as surgeons usually speak of an outer 
and an inner eondylus in this injury, although these 
names are not known to the anatomic nomenclature. 
The line of fracture does not, of course, always follow 
the same direction. 

These oblique fractures are true joint- fractures, and are 
not infrequently associated with marked displacement of 
the forearm at the elbow-joint. A provisional diagnosis 
may be arrived at by careful palpation of the articular 
prominences and the determination of abnormal mobility. 
If pain and swelling are marked, the examination should 
be conducted under anesthesia. Sometimes parts of the 
fractured surface and of the articular extremity itself may 
be felt. Accurate knowledge of the normal outlines and 
comparison with the sound side will usually enable the sur- 
geon to obtain a correct idea of the nature of the injury. 
In oblique fractures involving one of the condyles some ab- 
duction and adduction of the forearm is possible when the 
arm is in complete extension and the hand in supination, 
sometimes even without anesthesia. It is often possible 
also to determine which is the injured side, for the forearm 
can only be moved toward the sound side, movement 
toward the injured side being inhibited by the lateral liga- 
ment, which is still preserved if the line of fracture passes 
through the middle of the joint, and only one condyle 
is separated. 

The most common form of oblique fracture, and one 
that constitutes an injury of frequent occurrence, is — 

(c) The external oblique fracture [fractura obliqua 
externa, fractura condyli externi), or fracture of the external 
condyle' (Plate 36, Fig. 4 ; Plate 37, Fig. 1 and 1 a). It 
is produced by direct violence applied to the outer portion 



182 FRACTURES AND DISLOCATIONS. 

PLATE 37. 

Valgus and Varus Position of the Elbow after Fracture of 
the Lower End of the Humerus.— Fig. 1.— Old oblique fracture 
of the lower end of the humerus with the production of cubitus valgus. 
The specimen shows the intense alteration at the joint which occurred 
after the splitting-off of the capitellum humeri (compare Plate 36, Fig. 
4). Arthritis deformans of the joint : cushion-like thickening of the 
head of the radius, atrophic condition of the cartilaginous articular 
extremities with moderate thickening of the surrounding bone. 
(Author's collection. ) 

Fig. 1 a. — The same condition as shown in figure 1, seen in the 
living subject. The patient, a man thirty-four years of age (J. Janker, 
1884), two years previously had sustained a fracture which resulted in 
deformity at the elbow. The illustration was copied from a photo- 
graph. ( Author ' s observation . ) 

Fig. 2. — Old fracture of the lower end of the humerus with the pro- 
duction of a cubitus varus. The articular process in the specimen 
shows little change. The deformity resulted from a badly united 
supracondylar oblique fracture. The specimen shows thickening of the 
lower end of the humerus in the anteroposterior direction ; slight de- 
gree of arthritis deformans. (Author's collection.) 

Fig. 2 a. — Cubitus varus in the living subject, after fracture of the 
lower end of the humerus. (Author's observation.) 



of the joint, or indirectly by transmission of the force to the 
outer portion of the joint through the radius (fall on the 
hand), or by transmission through the olecranon laterally 
from within outward (fall on the inner portion of the 
elbow with the arm in abduction). The external oblique 
fracture (glenoid condyle) corresponds in a certain sense 
to a backward and posterior dislocation of the forearm. 

Symptoms. — Abnormal mobility of the extended forearm 
inward. The disappearance of the normal position of ab- 
duction when the arm is in extension (later the arm forms 
an angle with the vertex presenting outward). Longi- 
tudinal compression of the forearm in abduction produces 
violent pain ; the outer condyle can readily be felt on 
the articular fragment, which exhibits abnormal mobil- 



T<tl>.:j?. 





Eig\ 






Fig.Jia 

lUh.Anst E Reicfitwld. Munch en. 



FRACTURES OF THE UPPER EXTRE3IITT. 183 

itv and crepitus. The fragment is often displaced upward 
by the pressure of the radius, or, rather, the action of the 
biceps and all the muscles of the forearm. There is cubitus 
valgus with anterior rotation of the articular portion 
(flexion). 

The prognosis in this fracture is, on the whole, unfavor- 
able ; the displacement of the fragment is apt to become 
permanent and interfere with the normal excursions of the 
joint by the presence of abnormal prominences on the 
bone (bony inhibition). In children and youthful indi- 
viduals the obstacles may in time be worn away and the 
function improved by proper exercises and the use of ap- 
propriate apparatus, such as Kocher's pendulum apparatus 
for the elbow-joint, which I am in the habit of ordering 
the patients to use at home. But even in these cases com- 
plete restoration of function is never obtained and the val- 
gus (cubitus valgus) may become permanent. (Compare 
Plate 37, Fig. 1 and 1 a.) 

Treatment. — Reduction under anesthesia by flexing the 
forearm in pronation and direct pressure. Splint dressing 
in the most advantageous position ; the position may be 
varied from time to time, the arm being placed half-way 
in extension, or in complete extension, and again for a time 
in flexion. A flexible, padded metal splint is very useful, 
because it may be bent to conform to the change of posi- 
tion at each change of dressing, which should take place 
every three or four days during the first two weeks, and 
later every other day. Permanent extension may also be 
used with advantage, the traction being applied in the 
longitudinal direction of the arm with the forearm flexed 
at the elbow. 

(d) Oblique internal fracture (fractura obliqua in- 
terna^ fractura condyli interni), or fracture of the internal 
condyle, is a much rarer occurrence. It is produced by 
pressure on the median portion of the articular border by 
a fall on the middle of the elbow. 

Symptoms. — Severe pain, accompanied by crepitus, is 



184 FRACTURES AND DISLOCATIONS. 

elicited by pushing the fragment upward; abnormal mobil- 
ity, permitting abduction when the arm is in extension ; 
and the fragment can be displaced directly toward the 
humerus. 

The prognosis, in view of the slight degree of deformity, 
is favorable. 

Treatment, — Reduction is effected by extension with the 
forearm bent at the elbow. Splint dressing. 

(e and f) Fractures of the Condyles {Fractura epi- 
condylica). — These fractures may occur separately or in 
combination with outward or inward dislocation. The 
diagnosis is really made by noting the displacement and 
mobility of the bony part. In moving the elbow it is 
found that moderate movements of flexion and extension 
are painless, while active flexion or extension gives exqui- 
site pain on account of the stretching of the lateral liga- 
ments and consequent tugging on the fractured surfaces. 
This symptom, which was first contributed by Hitter, is 
of course useless in little children, nor does it occur when 
the condyle is not only broken, but is also markedly dis- 
placed. 

(e) Fracture of the internal condyle (fractura epicon- 
dyli interni, fractura epitrochlece, Bahr). This is a com- 
mon injury ; it is rarely produced directly by a fall or blow 
on the condyle ; much more frequently indirectly by mus- 
cular action, being torn away with the internal lateral 
ligament in abduction, which, if continued, may add out- 
ward dislocation of the forearm to the injury. 

Symptoms. — The downward displacement of the movable 
condyle is sometimes very slight, sometimes very marked ; 
it may extend as far as the level of the trochlea. Circum- 
scribed ecchymoses. Abnormal abduction is possible. 

Treatment — In marked displacement of the fragment 
Kocher recommends operative fixation by means of su- 
tures ; in an old case, excision of the fragment. Kocher 
has often had occasion to study the anatomy of the joint 
in this operation, and believes that the fracture is always 



FRACTURES OF THE UPPER EXTREMITY. 185 

produced by muscular action and should be regarded, in a 
sense, as the first step in outward luxation (compare Plate 
39 ). He has even observed dislocation to take place sec- 
ondarily after this fracture. I have so far never been 
obliged to operate. 

(f) Fracture of the external condyle (fractura epicon- 
dyli externi, fractura epicapituli, Bahr). This is a very 
rare injury. I have seen it with inward dislocation of the 
forearm, just as the one just described occasionally accom- 
panies outward dislocation. Diagnosis and treatment are 
the same as for the last-described fracture. 

(g) Intra-articular Fracture Separating the Capi- 
tellum Humeri (Fraetura rotvlare partialis, Kocher; 
Frajdura processus articularis partialis). — This fracture is 
entirely intra-articular. The separated piece of bone lies 
in the joint as a movable body ("joint-mouse"); or it 
may become fixed in an abnormal position (Steinthal). It 
is produced by a fall on the hand, that is, by a blow from 
below, transmitted through the radius. In some cases, 
observed by Kocher in youthful individuals, there was 
more a peeling off of the cartilaginous investment with 
some adherent bony substance than a true fracture. 

Symptoms, according to Kocher : Sudden pain and 
appearances of a distortion ; slight bloody effusion into the 
joint ; somewhat later the arm is held at an obtuse angle 
and slightly abducted at the elbow ; the internal condyle 
becomes very prominent ; the head of* the radius appears 
to be subluxated ; that is, it appears wider on account of 
the diminution in the size of the capitellum. The only 
movements interfered with are extension and supination, 
which give great pain. It is said that the separated piece 
of cartilage can be felt between the external condyle and 
the head of the radius when the arm is in extension. The 
injury may be mistaken for fracture of the head of the 
radius. 

The treatment consists in removal of the loose bone 
through a lateral incision. 



186 FRACTURES AND DISLOCATIONS, 

PLATE 38. 

Backward Dislocations of the Forearm. — Fig. 1. — Anatomic 
specimen, showing a backward displacement artificially produced in 
the cadaver ; right arm. We see the shaft of the humerus and its 
lower articular extremity ; below and behind it, the dislocated head 
of the radius ; and at the upper end of the ulna the semilunar fossa. 
The external lateral ligament and annular ligament are faithfully re- 
produced. On the anterior surface of the humerus the biceps and its 
tendon, and, underneath, the brachialis anticus, may be seen. Behind 
the humerus the triceps with its insertion on the tip of the olecranon 
is discernible. 

Fig. 2. — The same dislocation in the living subject ; right arm. 
The arm is flexed at an obtuse angle ; the tip of the olecranon forms 
an abnormal prominence, to the inner side of which is another spher- 
ical prominence corresponding to the head of the radius. The longi- 
tudinal axis of the humerus, instead of being directed toward the end 
of the forearm, divides it into a short posterior and a long anterior 
segment. 

(h) Longitudinal Fracture at the Lower End of 
the Humerus {Fraetura intercondyliea, Htiter). (Com- 
pare Plate 36, Fig. 2.) T-fracture (Fraetura condylo- 
intercondylica). (Compare Plate 36, Fig. 3.) Y- and 
V-fractures (Double Oblique Fractures). — These severe 
fractures are often complicated not only with fracture at 
the upper articular extremity of the bones of the forearm 
(Plate 36, Fig. 1 b), but also with injury to the soft parts. 
The lower end of the humerus seems to be particularly 
liable to longitudinal fractures, as shown by the prepa- 
ration of Plate 36, figure 2, from a shot-wound of the 
diaphysis. 

The diagnosis is not impossible : all the lateral por- 
tions of the lower end of the humerus can be moved 
against each other and against the shaft of the bone. 

Treatment. — Antiseptic treatment of wounds in the 
soft parts. Extension dressing with the arm extended. 



Tab.38. 




\m 



^V 



Lilh . Aftst. /:' Retr/iliold. Muiichm . 



FRACTURES OF THE UPPER EXTREMITY. 



187 



5. ELBOW 

(A) Dislocations 

In the examination of dislocations of the elbow-joint an 
accurate knowledge of the outlines of the normal joint is 
indispensable. We feel the condyles, the olecranon, and 
their relations to one another in various positions of the 
joint ; underneath the external condyle the head of the 
radius is distinctly felt, especially if the forearm is alter- 
nately pronated and sup- 
inated. In dislocations 
the articular extremities 
can often be distinctly 
felt — the head of the 
radius with its central 
depression, the capitel- 
lum humeri, trochlea, and 
the upper end of the ulna. 
For the examination to be 
accurate, not only each 
individual bony promi- 
nence must be recognized, 
but the position of all the 
bony parts and their rela- 
tion to one another must 
be accurately demonstrat- 
ed, even if they cannot all 
be directly palpated. It 
is well to have a skeleton 
of an arm at hand in set- 




Fig. 81. — Recent backward dislo- 
cation of the left forearm in a boy 
fourteen years of age (Kriiger, 1896). 
Swelling, prominence of the olecra- 
non, shortening of the forearm are 
seen. The dislocation was reduced 
and perfect recovery ensued. 



ting these injuries. 

We distinguish dislocation of both bones of the forearm 
{luxatio antibraehii), and luxation of one bone alone (lux- 
atio radii, luxatio ulnce). 

(a) Backward Dislocation of the Forearm (Plate 
38). — This is the easiest dislocation to produce in the 



188 FRACTURES AND DISLOCATIONS. 

cadaver. The arm need only be overextended to produce 
a tear in the anterior segment of the articular capsule ; the 
olecranon during this movement is braced against the pos- 
terior supratrochlear fossa, and after the bones have been 
sufficiently forced apart, the forearm is suddenly pushed 
backward and then flexed at the elbow-joint — the disloca- 
tion is complete. The arm is fixed at an obtuse angle at 
the elbow. Further flexion is prevented by the pressure 
of the coranoid process against the articular extremity of 
the humerus and by the pull of the triceps muscle. 




Fig. 82. — Backward dislocation of the forearm ; skiagraph. Old 
dislocation in a man twenty-five years of age (A. PreDgschart). The 
dislocation was reduced and a good result obtained. 

This dislocation frequently occurs in the living subject 
and is often produced by the same mechanism. The in- 
jury is said also to be produced by overflexion and forced 
lateral movement or by a force striking the lower end of 
the humerus directly from behind. 

The symptoms are easily understood. The promi- 
nence of the olecranon is conspicuous ; the lower end of 
the humerus is hidden under the soft parts at the bend of 
the elbow, but may be felt somewhat more distinctly if 



FRACTURES OF THE UPPER EXTRE3IITY. 189 

Method of Reducing a Backward Dislocation of the Forearm. 




Fig. 83. — Overextension at the elbow — the first step in the manipula- 
tion. 



Skeleton : 




Fig. 84. — Overextension. 





Fig. 85. — Traction on the forearm. Fig. 86. — Flexion. 



190 FRACTURES AND DISLOCATIONS. 

PLATE 39. 
Outward Dislocation of the Forearm and Separation of the 
Internal Condyle. — Fig. 1. — Anatomic specimen from a dislocation 
of this kind on the right arm ; anterior view. The lateral displace- 
ment of the bones of the forearm is very noticeable. The articular 
surface of the ulna articulates with the lateral portion of the trochlea 
and of the capitellum humeri ; the head of the radius is outside of the 
joint. The separated internal condyle is attached to the ulna by the 
internal lateral ligament. 

Fig. 2. — Same dislocation in the living subject, right arm, anterior 
view. There is little change in the anterior and posterior contour of 
the arm, but on the outer side the head of the radius forms a marked 
prominence. The findings are readily confirmed by palpation, espe- 
cially when the forearm is rotated from pronation to supination. 

Fig. 3. — Bone specimen of the same dislocation and in the same posi- 
tion as in figure 2, seen from the outer side. Eight arm. The illus- 
tration is intended to explain figure 2. 

the dislocation is recent and the swelling is not very great. 
It can be felt close under the skin only when there has 
been extensive laceration of the soft parts (brachialis anti- 
cus, nerves, and vessels). In compound dislocations it 
may even be seen through a tear in the skin. The line 
of the humerus does not end at the extremity of the fore- 
arm, as under normal conditions, but intersects it so as to 
leave a small portion projecting behind. Olecranon and 
head of the radius can be directly palpated and their ex- 
cursions determined by moving the forearm. The dis- 
tances between the condyles and the olecranon are abnor- 
mal. The lower end of the humerus does not present 
abnormal mobility as in supracondylar fracture. The 
humerus is shortened, and the dislocation cannot be made 
to disappear by drawing the forearm forward. 

The diagnosis may present some difficulties in the pres- 
ence of complicating injuries, such as fracture of the coro- 
noid process. Simultaneous supracondylar fracture of the 
humerus and fracture of the olecranon have also been 
observed. In fracture of the trochlea the forearm and 



Tab.39- 






Fig.,3. 




lith.Anst. /: Reichhold, Munclien . 



FRACTURES OF THE UPPER EXTREMITY. 191 

fragment may be displaced backward with luxation of the 
head of the radius. 

If complications are present, they may render the 
prognosis unfavorable ; otherwise passive and active mobil- 
ity should be restored after reduction. 

Treatment. — The method of reduction is shown in 
figures 83-86. As in every hinge-joint, reduction requires 
more than a simple pull, no matter how strong it may be. 
It must be effected without using force, as if the surgeon 
were toying with the joint, so to speak ; anesthesia is 
usually required. The forearm in supination is first over- 
extended so as to dislodge the coronoid process from the 
supratrochlear fossa. Moderate traction then draws the 
forearm forward, while the other hand seizes the injured 
elbow and controls the position of the parts ; or the thumb 
may be braced against the lower end of the humerus and 
the other fingers, especially the third and fourth, against 
the head of the radius and olecranon behind, and by direct 
pressure assist in the act of reduction. Flexion of the arm 
is now found to proceed without any obstacle ; the disloca- 
tion disappears and the normal contact between the articu- 
lar surfaces is restored. 

After-treatment according to general principles ; fixa- 
tion of the arm for two days, the dressing being changed 
at short intervals and massage administered ; later passive 
movements. 

(b) Lateral Dislocation of the Forearm (Plate 39). — 
Lateral dislocations at the elbow-joint are not rare ; out- 
ward dislocation is more frequent than inward, and is 
usually combined with fracture of the internal epicondyle. 
This fracture is the direct result of the contusion sustained 
during the fall which produces the dislocation ; or it may 
be a sprain fracture due to the pull of the lateral ligament. 
It always affects the condyle furthest removed from the 
forearm ; hence in outward dislocation the internal con- 
dyle is fractured, and, inversely, in inward dislocation the 
external condyle. 



192 FRACTURES AND DISLOCATIONS. 

The forearm and humerus are still in contact, but the 
articulation is abnormal. Thus, in outward dislocation 
the ulna articulates with the trochlea and the head of the 
radius projects beyond the joint. As a rule, the forearm is 
at the same time displaced backward, producing the combi- 
nation of lateral and posterior dislocation (luxatio posterior 
externa or poster o-later alls). While backward dislocation 
may occur without destroying the integrity of the lateral 
ligaments (although the internal ligament is, as a matter 
of fact, generally torn), lateral luxation is usually asso- 
ciated with great destruction of ligaments and fracture of 
the epicondyle. This variety is also described as an 
incomplete dislocation, in contradistinction to complete 
dislocation of the bones in which no portion of one articu- 
lar surface remains in contact with any portion of the 
other. 

A lateral dislocation can only be produced by exagger- 
ated movements of abduction or adduction. The capsule 
is greatly distended and sometimes presents a lateral tear. 

The symptoms of a complete lateral dislocation to the 
outside, for instance, are unmistakable and need no descrip- 
tion. 

In incomplete outward dislocation (Plate 39) the promi- 
nence formed by the head of the radius is distinctly seen 
and felt. To the inner side, part of the trochlea can be 
seized between the fingers, and the separated internal epi- 
condyle may be felt or appears as a marked prominence. 
By gently moving the parts under anesthesia a clear con- 
ception of the conditions is at once obtained. 

[Recently Eversmann x has reported' two interesting 
observations of the outward lateral dislocation of the 
elbow-joint. In both cases the fragmented internal epi- 
condyle had become displaced into the joint, and after the 
reduction of the dislocation, the interposition of this frag- 
ment produced symptoms and restricted function. Both 

^eut. Zeitschr. f. Chir,, 1901, Bd. lx, p. 528. 



FRACTURES OF THE UPPER EXTRE31ITY. 193 

were subjected to operation with good results. TheRont- 
geD photographs of these two cases are quite clear. This 
possibility should always be borne in mind in this rare 
form oi* dislocation. — Ed.] 

Incomplete inward luxation (luxatio postwo-medialis) pre- 
sents the external epicondyle in marked anterior displace^ 
ment, or completely separated from the bone. The ulna 
projects beyond the inner line of the arm and its articular 
surface can be felt ; the head of the radius articulates with 
the trochlea ; and part of the capitellum humeri may be 
palpated. 

The prognosis depends on the complications. 

Treatment. — Reduction is effected under anesthesia 
with the least amount of injury to the patient by overex- 
tending the arm under direct lateral pressure with the other 
hand, followed by traction and flexion. If something is 
found interposed between the articulating surfaces, exag- 
gerated lateral movements, overextension with abduction, 
etc., are sometimes successful. If efforts at reduction fail, 
early removal of the obstacle through an incision is indi- 
cated, preferably by means of a bilateral arthrotomy. 
Excellent results may be obtained by this procedure. 

(c) Forward Dislocation of the Forearm (Luxatio 
antibrachii anterior). — This is a very rare injury. It was 
formerly said that it never occurred without simultaneous 
fracture of the olecranon. It may be produced by a fall or 
blow on the olecranon while the arm is in extreme flexion. 

Symptoms. — The prominence of the olecranon is missed 
from its normal position, and the outline of the lower end 
of the humerus can be felt on the posterior side of the bone. 
If the outer side of the olecranon is still in contact with 
the trochlea, the arm being almost in extension, an incom- 
plete luxation exists. In complete dislocation the tip of 
the olecranon is found in front of the articulating surface 
of the lower end of the humerus, and the arm is bent at an 
acute angle. Reduction is effected by direct pressure, with 
moderate extension. 
13 



194 FRACTURES AND DISLOCATIONS. 

(d) Divergent dislocation of the forearm (luxatio 
antibraehii divergens), the ulna being displaced backward 
and the radius forward, so that the humerus is driven like 
a wedge between the two bones of the forearm, is a very 
rare injury. The abnormal position of the various parts 
of the bone can be determined by direct palpation. In re- 
ducing the dislocation each bone is to be treated separately, 
the ulna by overextension and traction, and then the radius 
by direct pressure. 

(e) Isolated dislocation of the ulna is an injury that 
occurs very rarely by a fall on the hand in overextension 
and pronation of the forearm. The symptoms are the 
same as those of a posterior dislocation, except that there 
is no displacement of the head of the radius. The elbow 
is in varus position and the ulnar side of the forearm is 
shortened. Reduction is effected by means of overexten- 
sion and traction. 

(f) Isolated dislocation of the radius is somewhat 
more common and occurs in various forms. Injury of the 
musculo spiral or radial nerve has been observed as a com- 
plication. The head of the radius may be displaced back- 
ward, forward, or outward : 

Uncomplicated outward dislocation is a very rare form, 
the dislocation being more frequently associated with frac- 
ture in the upper third of the ulna (Plate 43). The head 
of the radius may be felt at the outer border of the exter- 
nal condyle, the radial side of the forearm is shortened; 
the elbow is, therefore, in valgus position. Reduction is 
effected by direct pressure ; sometimes the elbow must be 
brought into varus position. 

Backward displacement is very rare. It is readily 
recognized by palpation of the head of the radius. The 
elbow is midway between pronation and supination. The 
patient cannot perform extension or supination. Reduc- 
tion is effected by direct pressure, assisted by forcible 
traction on the forearm, which must be brought into varus 
position. 



FRACTURES OF THE UPPER EXTREMITY. 195 

Anterior dislocation is somewhat more common. It is 
produced by a blow against the head of the radius from 
behind^ or by a fall on the hand in pronation. The head 
ot' the radius is found in front of and above the capitellum 
humeri and forms a prominence in the region of the supi- 
nator muscles. The forearm is slightly flexed and pro- 
nated ; active supination is impossible; flexion beyond a 
right angle is impossible. The radial side of the forearm 
is shortened, unless the injury is complicated by a fracture 
in the upper third of the ulna (q. v.). Reduction is best 
effected by vigorous traction and simultaneous supination 
with the elbow in flexion. 

In all these cases of isolated dislocation of the radius, 
the annular ligament is torn, or the head of the bone 
escapes from beneath it. Not rarely, especially in anterior 
dislocation, reduction becomes difficult, if not impossible, 
on account of interposition of portions of the capsule. 
Arthrotomy is then indicated, and reduction is forcibly 
secured by removing the interposed tissues. The same 
procedure is indicated in old cases. The longitudinal in- 
cision is made on the radial side of the joint ; if the joint 
is entered from the front, there is danger of dividing the 
musculospiral nerve. In very severe cases arthrotomy 
may have to be abandoned in favor of resection. 

The after-treatment of all these dislocations must be car- 
ried out on general principles. 

(B) Intra-articular Injuries 

Various intra-articular injuries may be united under the 
designation derangement interne. One example of this has 
already been referred to in separation of the capitellum 
humeri (page 185). Another injury deserves special men- 
tion, not because the etiology and symptom -complex are 
not perfectly well known, but because the anatomic details 
still form the subject of controversy. The accident occurs 
in little children and is produced by the nurse or attendant 



196 FRACTURES AND DISLOCATIONS. 

violently pulling the child's arm, either to prevent it from 
falling or to pick it up when it has slipped down from the 
lap, etc. 

Symptoms. — The arm hangs at the side and the elbow 
is held immovable in pronation ; there is no demonstrable 
deformity. Attempt at supination is very painful, but if 
it is carried out and traction is at the same time applied, 
followed by flexion, the pathologic condition disappears. 
The child can use its arm again, although it is better to 
have it carried in a sling for a few days. This symptom- 
complex, which recurs again and again in a most typical 
form, is regarded by some surgeons as the result of an in- 
complete dislocation of the radius forward, by others as the 
result of a compression of the uninjured articular capsule 
at its posterior side, between the head of the radius and 
the humerus. 

6. FOREARM 

An explanation of the frequency of fractures in the fore- 
arm is given by its function in the performance of work 
and in protecting the body against injuries. We distin- 
guish between fractures of the forearm — that is, of both 
bones — and isolated fractures of the ulna and radius alone. 

(A) Fracture of Both Bones of the Forearm (Frac- 
tura Antibrachii) 

This fracture is usually the result of direct violence, 
either a fall or a blow. In children infractions with 
bending of the forearm (greenstick fractures) are common. 

Symptoms. — As a rule, the presence of a fracture is at 
once suggested by the angular deformity (ad axin) ; on 
careful examination abnormal mobility and crepitation are 
found. As the fractures preferably affect the middle 
third of the forearm, these phenomena can, as a rule, be 
demonstrated with ease and positiveness. Fractures of 
the forearm bones near their lower end will be discussed 



FRACTURES OF THE UPPER EXTREMITY. 197 





Fig. 87 a. Fig. 87 b. 

Figs. 87 a and 87 b. — Fracture of the forearm with marked de- 
formity. The fragments were reduced by operation and the bones 
united by suture. Skiagraph. The patient, J. Schmidt, seventeen 
years old, fell from his wheel and struck on the left arm. Fracture 
of the forearm, with marked dislocation, especially of the lower radial 
fragment which completely overlies the shadow of the seat of fracture 
in the ulna. The latter presents only slight displacement of the frag- 
ments (Fig. 87 a). Although the patient was anesthetized, reduction 
was impossible; the fragments were therefore exposed by an incision 
and reduction effected by means of silver wire. Good result (Fig. 
876). 



198 FRACTURES AND DISLOCATIONS. 

. PLATE 40. 

Fractures through the Middle of the Forearm. — Fig. 1.— 

Typical displacement of the fragments in fracture of the right forearm. 
The picture was taken from a boy. When he first came under obser- 
vation, the fragments had become united by bony union. The frac- 
ture was reduced under anesthesia, the arm was carefully fixed in 
extension, and bandaged to a long dorsal splint. Good recovery re- 
sulted. 

Fig. 2. — Bones of the right forearm, anterior view, showing united 
fracture with position of the fragments similar to that in figure 1. In 
the radius the union is bony; the ulna shows a false joint at the seat of 
fracture; both present the same angular deformity. (Author's collec- 
tion. ) 

Fig 3. — Specimen of fracture of left forearm, united in compara- 
tively good position. The two bones are united at the seat of fracture, 
not by a firm mass of bone, but fortunately by a neoarthrosis. In the 
region of the interosseous crest each bone presents a process tipped 
with a kind of articular surface, which articulates with that of the 
prominence on the other bone. In the radius the process is found 1 
cm. above the seat of fracture, springing from the shaft, which presents 
practically no alteration. The fracture of the radius was a multiple 
one; in addition the peripheral fragment presents a longitudinal frac- 
ture which extends obliquely into the joint. The lower articular ex- 
tremities of both bones exhibit a moderate degree of arthritis defor- 
mans. Pronation and supination were evidently reduced to a mini- 
mum. 



more in detail in connection with typical epiphyseal sepa- 
ration of the radius. If both bones are broken at the 
same level,, the displacement is, as a rule, greater than 
when the lines of fracture are separated by an interval. 

The relative position of the lines of fracture is of some 
importance for the prognosis, as is also the question 
whether the dislocation has brought the bones nearer 
together and led to extensive laceration of the interosseous 
ligament, for this may be followed by cicatricial contrac- 
tion and partial ossification of the ligament, and, in addi- 
tion, the bones may come into lateral contact with one 



Fiff.l. 



Tdb.40. 






^^ 



Fig, £. 




„ • 






Fig.3. 



LitfaAnst t: ReichlL 



FRACTURES OF THE UPPER EXTREMITY. 199 

another, be it by means of bony union or by a kind of 
conical articulation, as shown in Plate 40, figure 3. It 
follows that pronation and supination may be greatly inter- 
fered with. In the leg complications of this character are 
quite immaterial, but in the forearm they may produce a 
marked degree of disability. 

Fracture of both bones of the forearm near their 




Fig. 88. — Supracondylar fracture of both bones of the forearm 
(Minna Houdelet, sixty years old, 1890). (Compare Plate 46 and 
Plate 47, Fig. 1.) 

lower extremity deserves especial notice ; it is comparable 
to a supramalleolar fracture of the leg, hence the term supra- 
condylar has been proposed. This fracture, like typical 
epiphyseal separation of the radius, is produced by a fall 
on the hand. Owing to the marked deformity, the diagno= 
sis rarely presents any difficulties. 

The treatment calls for careful reduction and fixation, 
either in supination or midway between pronation and 



200 FRACTURES AND DISLOCATIONS. 

PLATE 41. 

Various Fractures of the Forearm and Normal Epiphyseal 
Lines. — Fig. 1. — Specimen of fracture of the forearm (right) with 
cohesion of the callus of both bones at the seat of fracture. This 
unfortunate condition is due partly to the abundance of callus and 
more particularly to the fact that the two fragments of each bone tend 
to converge. The illustration distinctly shows this abnormal direc- 
tion of the four fragments. It is probable that the splint in this case 
was too narrow, and that the bones weie forced together by the pres- 
sure of the bandage. 

Fig. 2. — Isolated fracture of the radius above its middle, showing 
the effects of the biceps on the position of the upper fragment. This 
illustration, which was faithfully copied from nature (artificial speci- 
men) , represents the forearm and hand with a portion of the arm. The 
forearm is in pronation, but the upper fragment of the humerus is 
rotated outward (supination) by the action of the biceps muscle, 
the function of which being, as is well known, supination and 
flexion of the supinated forearm. The supination of the upper frag- 
ment is recognized by the position of the tuberosity on the radius, by 
the point of insertion of the biceps, and especially by careful examina- 
tion of the line of fracture; on the lower fragment a loss of substance 
is seen on the lower border of the fractured surface corresponding to a 
slight projection visible on the upper fragment. The projection and 
the loss of substance are not opposite one another; the outward rota- 
tion of the upper fragment (supination) having caused the projection 
to move through almost 180 degrees. The lesson to be drawn from 
this is that even in isolated fracture of the radius the arm must be 
dressed in supination or midway between supination and pronation. 

Fig. 3. — Epiphyses of the bones that enter into the formation of 
the elbow-joint, showing various centers of ossification. Frontal sec- 
tion, right side. The posterior sawed surface seen from in front. We 
see the center of ossification of the capitellum, the internal condyle, 
and the head of the radius. 

Fig. 3 a. — Sagittal section through the upper end of an ulna from 
a child. 

Fig. 4. — Lower epiphyses of the bones of the forearm. 



supination, according to general principles. For this 
reason the treatment of fracture of the forearm is particu- 



TubJn 



Fig, 




Fic/.J. 




Fuj.l. 



Eiq.Z. 




Ltth.Anst. /■: HeuiihoUI. Miiiicha 



FRACTURES OF THE UPPER EXTREMITY. 201 

larly important and requires expert skill and conscientious 
attention on the part of the surgeon. The object must 
be to secure bony union of the fragments with each bone 
in good position, and unimpaired motion both of the adja- 
cent articulations and of the two bones themselves. Care 
is also required not to produce any injury with the ban- 
dage. The dressing may do harm if the pressure of the 
circular bandage is such as to force the bones apart and 
bring the extremities of the fragments together at the seat 
of fracture in such a way as to induce complete cohesion 
by an abundant callus-formation (Plate 41, Fig. 1). The 
splint must therefore be a broad one ; it may be improvised 
from cardboard reinforced with small strips of wood broad 
enough to project beyond the forearm on each side. 
Another important point, after careful reduction, is the pri- 
mary position of the forearm. The elbow is bent at a 
right angle and the wrist extended ; and both joints must 
be included in the dressing. The chief question is, how- 
ever, Should the forearm be in pronation or in supination? 
From what has just been said, it is evident that a position 
in which the two bones cross each other must be avoided 
at any cost. From this point of view parallel position of 
the bones — that is, complete supination — is the most desira- 
ble position. Another factor to be considered is the effect 
of the muscles on the fragments. Plate 41, figure 2, 
serves to remind us of the effect of the biceps on the upper 
fragment of the radius. This muscle is a supinator. 
Should the limb therefore be bandaged with the hand in 
pronation, while the upper fragment of the radius is in 
supination, the treatment would result in a very imperfect 
recovery with loss of supination. 

Furthermore, an angular displacement of the radius at 
the seat of fracture may interfere with the movement or 
unfolding of the interosseous ligament, thereby diminish- 
ing the excursions of the bone in supination. 

We conclude, therefore, that after careful reduction of 
the fragments, the arm is to be fixed in a position of sup- 



202 



FRACTURES AND DISLOCATIONS. 



ination on a splint that must not be too narrow. The 
splint may be applied either to the dorsal or the volar 
side of the arm; or, better still, fixation may be secured 
by the use of two splints, a long and a short one. It is 
in these fractures that especial care becomes necessary to 
see that the splints are well padded ; that the bandage is 




Fig. 89. — Improvised extension dressing for ambulatory treatment 
of a fracture of the forearm with a tendency to angular displacement 
of the fragments. 



not too tight ; and that the hand and fingers are left ex- 
posed for constant inspection. For it is in such cases that 
neglect of these precautions, especially the application of 
a circular plaster-of-Paris bandage immediately after the 
injury, is most apt to produce gangrene and ischemia (see 
General Considerations). The dressing should be changed 



FRACTURES OF THE UPPER EXTRE3I1TY. 203 

at the end of about a week, and the position of the frag- 
ments at this time carefully examined. If one observes a 
tendency to angular displacement, with the vertex of the 
angle on the extensor surface, it may be successfully com- 
bated by applying an appropriate splint to the extensor 
side and bandaging the arm in extension. In some cases 
an extension bandage by means of Cramer's splints may 
be improvised (Fig. 89). Gentle passive movements and 
massage should be begun early. The normal course may 
be disturbed by various accidents, such as delayed callus- 
formation, the formation of a false joint, etc. These com- 
plications must be treated on general principles. 

[The treatment of fracture of both bones of the forearm 
is a very important one. Not only must we avoid too 
narrow splints, which press the bones together at the seat 
of fracture, but it is very important to avoid excessive 
pressure, which can be easily produced in this region. 
Pressure sufficient to do harm is not necessarily associated 
with pain and discomfort to the patient. This undue 
pressure produces marked anemia of the muscles, which if 
present a number of days is usually followed by an inter- 
stitial myositis. The muscle is replaced by fibrous tissue 
and the loss of function which results is a permanent one. 
This can be avoided by well-padded splints. Blanket un- 
questionably is the best form of padding. If the fracture 
of the shaft is near the elbow-joint, the elbow should be 
fixed ; that is, the anterior or volar splint should be a 
right-angled wire or tin splint. The posterior splint 
should extend from the tip of the olecranon at least to the 
knuckles. In fracture of the middle of the shaft of these 
bones or lower down, it is unnecessary to fix the elbow- 
joint unless, on account of position of the fracture and a 
tendency to displacement, we wish to fix the forearm in 
forced supination or semisupination. This can only be 
accomplished by the fixation of the elbow. In children 
frequent dressings and massage are very important in 
these fractures. Such measures allow frequent inspection 



204 FRACTURES AND DISLOCATIONS. 

PLATE 42. 

Fracture of the Olecranon and Coronoid Process.— Fig. 1. 
— Anatomic specimen of fracture of the olecranon, artificially pro- 
duced. Posterolateral view, right arm. The broken tip of the olec- 
ranon is drawn upward by the triceps muscle. The separation 
between the fragments is increased to the maximum by the flexed posi- 
tion of the forearm ; the elbow-joint is widely opened, as always hap- 
pens in fracture of the olecranon. The cartilaginous articular surface 
of the lower end of the humerus is exposed on each side ; the head of 
the radius and external lateral ligament are to be seen. 

Fig. 2. — Bone specimen of an old fracture of the olecranon in which 
the union was fibrous. Traces of arthritis deformans. (Author's col- 
lection. ) 

Fig. 3. — Section from a fracture of the olecranon in which the union 
was ligamentous. 

Fig. 4. — Fracture of the coronoid process with the brachialis anticus 
muscle, which is capable of displacing the upper fragment. Left fore- 
arm, internal view. 

and, if necessary, correction of the position of the frag- 
ments. Tendency to displacement is frequently marked. 
Before bony union is complete, if there is slight angular 
deformity it can be molded into a proper position by mas- 
sage and the proper adjustment of pads. This is espe- 
cially true of the greenstick fracture in children. The 
fingers should never be fixed in the dressing. — Ed.] 

(B) Fractures of the Ulna 

(a) Fracture of the Olecranon (Plates 36 and 42). — 
This fracture is usually produced by a fall on the elbow, 
— that is, by direct violence, — very rarely by muscular 
action of the triceps or by compressing the olecranon 
against the posterior surface of the humerus in overexten- 
sion. 

The symptoms are obvious, as one usually has to deal 
with a transverse fracture through the middle of the olec- 
ranon, with distinct separation of the fragments. The 



Tub. 42. 




T 





Fig. 4-. 



m 



x 




Lith.Anst /■' ReichtxaUl . Aftinchen. 



FRACTURES OF THE UPPER EXTREMITY. 205 

upper fragment is drawn upward by the triceps. Owing 
to the superficial position of the olecranon, the condition 
is readily determined by palpation. The joint and the 
remaining bony prominences of the articular region re- 
main intact, except, of course, that the extravasation pro- 
duced by the fracture also affects the joint. The patient is 
unable to extend the arm. As a rule, the upper fragment 




Fig. 90. — Skiagraph of a fracture of the olecranon. Keuter, a roofer, 
eighteen years old, fell on his elbow. Clinically the symptoms of 
fracture of the olecranon were found. In the skiagraph there is found, 
in addition to this fracture, a fissured fracture of the upper articular 
extremity of the ulna, separating the base of the coronoid process. 
Good recovery. 

may be brought down far enough to elicit crepitation by 
moving it from side to side. 

If the contact of the fragments has been maintained by 
the partial preservation of the periosteal investment and 
the lateral fibers of the tendon, the prognosis is very fav- 
orable for firm bony union without operation. If the 
fragments are separated, bony union is hardly to be ex- 



206 FRACTURES AND DISLOCATIONS. 

pected. In most cases the bones become united by con- 
nective tissue. This is partly due to the fact that the 
fragments are not covered by periosteum on the side 
directed toward the joint, but possess a thick cartilaginous 
investment, Avhile on the outer side they are covered with 
a dense layer of fibrous tissue (insertion of the triceps 
tendon). For this reason callus-formation is relatively 
slight. 

Treatment. — Attention must first be directed to the 
factors which produce the separation ; hence the arm must 
be dressed in complete extension, because in this position 
the lower fragment is brought as near as possible to the 
upper, which is drawn upward by the triceps. It is often 
advisable to evacuate the blood from the joint by aspira- 
tion if it appears that the tension of the effusion contributes 
to the separation of the fragments. The upper fragment 
is then fixed as near the lower as possible. This fixation 
is best accomplished by means of narrow strips of adhe- 
sive plaster passed around the tip of the olecranon and at- 
tached to the flexor surface of the forearm on both sides. 
Primary suture of the fragments may be resorted to under 
certain conditions, if the surgeon has complete confidence 
in his asepsis ; but it is not to be recommended as a routine 
method, and should be attempted only when all the facili- 
ties of a clinic are at hand. 

For the rest, the treatment is the same as that of any 
other articular fracture. It is important to begin massage 
of the triceps early ; and it may be pointed out in this con- 
nection that massage treatment of olecranon fractures, like 
that of fractures of the patella, has recently given very 
good results. 

[In fractures of the olecranon, if the fragments are not 
fixed by suture the treatment should always be in forced 
extension. The arms should be placed on one long ante- 
rior splint extending from a point just below the insertion 
of the pectoralis major to beyond the finger-tips ; the upper 
fragment and triceps fixed and pulled down by adhesive 



FRACTURES OF THE UPPER EXTREMITY* 207 

straps. The non-operative treatment of fractures of the 
olecranon has many objections. In the first place, there 
is so much swelling and joint effusion that the full exten- 
sion dressing cannot be applied for three or four days ; in 
the second place, this position of full extension and abso- 
lute rest to the joint must be maintained for at least two 
weeks. At this time we are between two dangers : fur- 
ther prolonged fixation and extension is likely to result in 
more or less ankylosis of the elbow-joint, because in this 
fracture there is always some injury of the capsule and the 
synovial membrane, while, on the other hand, early passive 
motion and the change of the position to one of flexion are 
very apt to separate the fragments. For this reason many 
surgeons prefer the immediate operative treatment of this 
fracture. The operation is very simple and can, if necessary, 
be performed under cocain. The fragments can be per- 
fectly approximated by a single silver wire. If there is 
much swelling, the operation can be delayed for a few days 
without harm. At the operation the most careful technic 
should be maintained. After the approximation of the 
fragments and closure of the wound without drainage, the 
arm can be fixed for a few days in full extension ; after 
three or four days the arm can be placed in a position of 
flexion, which position can be increased every few days up 
to a position of almost complete flexion. From my own 
experience the operative treatment of this fracture has 
given better results not only for the union of the frag- 
ments, but for the function of the elbow-joint. — Ed.] 

(b) Fracture of the Coronoid Process (Plate 42). — 
This fracture is rare and is usually observed in combina- 
tion with backward dislocation of the forearm. It is only 
when the line of fracture runs through the base of the 
process that the fracture is acted on by the brachialis an- 
ticus, for this muscle is attached not to the tip, but at a 
point considerably below the tip of the process. [This 
anatomic point is frequently forgotten. — Ed.] The fracture 
in its uncomplicated form is produced chiefly by a force 



208 FRACTURES AND DISLOCATIONS. 

PLATE 43. 
Isolated Dislocation of the Head of the Radius with Frac= 
ture of the Upper Third of the Ulna ; Marked Displacement of 
the Fragments. 

Fig. 1. — Anatomic preparation of this typical injury. Left arm, 
outer view. The ulna presents marked displacement of the fragments. 
Above the olecranon the head of the radius is in plain view ; between 
the two bones is the anconeus muscle, in contact with the anterior 
surface of the upper ulnar fragment. In front of the lower ulnar 
fragment the extensor carpi ulnaris has been exposed. Below the 
fragment the flexor digitorum prof undis and flexor carpi ulnaris are to 
be seen. 

Fig. 2. — The same injury in the living subject. Right arm, outer 
view. Copied from the photograph of an adult. (Author's observa- 
tion. ) The angular deformity of the ulna at the seat of fracture and 
the prominence formed by the head of the radius are very conspicuous. 

Fig. 3. — Bony specimen of the same injury, also showing the left 
arm from without in the same position. This may help to explain 
figure 2. The head of the radius is displaced more anteriorly in this 
specimen, while in figure 2 the displacement is more external. [This 
is a very rare fracture. — Ed.] 

that brings the lower end of the humerus against the an- 
terior side of the ulna — that is, against the coronoid pro- 
cess. 

The symptoms are those of a severe joint-injury. 
Owing to the thickness of the soft parts on the anterior 
aspect of the joint, the fragments cannot be directly pal- 
pated. By careful palpation, however, it is discovered 
that the bony prominences are intact. The olecranon 
sometimes projects a little backward (subluxation), but can 
be replaced by slight traction on the forearm. If the elbow 
is flexed at an obtuse angle, this displacement of the 
olecranon can be brought about by pushing the forearm 
backward and immediately reduced with the production of 
crepitus. 

The treatment includes complete reduction by drawing 
the forearm forward, followed by fixation in acute-angled 



Tab A3. 







Fig J. 




Fig, 3, 



Lith.Anst /.' Reichliold, Mtwchen 



FRACTURES OF THE UPPER EXTREMITY. 209 

flexion. In general, the management is the same as that 
of other joint fractures. 

"This fracture is quite frequently overlooked. The 
callus-formation may be excessive, and later very much 
restrict flexion at the elbow-joint. Recently Carl Beck x 
has reported three very interesting cases illustrated with 
X-ray photographs. I have observed one case in which 
it was necessary to chisel away the callus about the coro- 
noid process in order to restore joint function. 2 — Ed.] 

(c) Fracture of the Upper Third of the Ulna with 
Dislocation of the Head of the Radius (Plate 43). — 
Those portions of the limbs which contain two bones — 
L e., the forearm and leg — present certain typical altera- 
tions which are quite easy to explain. If both bones are 
broken, there may be any degree of deformity ; the behav- 
ior of the two bones is identical. If, however, one bone 
only is broken, the remaining bone acts as a sort of splint, 
and no doubt prevents the production of a high degree of 
displacement. Hence, if on superficial examination there 
seems to be a fracture of only one bone, with marked dis- 
placement of the fragments, the other bone, as a rule, must 
have sustained a fracture or a dislocation. The observant 
practitioner will notice in his practice that fractures of the 
ulna with marked deformity are usually attended with 
dislocation of the head of the radius, and that fractures of 
the tibia are similarly combined with dislocation of the 
head of the fibula. 

Fracture of the ulna in its upper third, with marked 
angular deformity and shortening of the bones, combined 
with dislocation of the head of the radius which is usually 
anterior, constitutes a typical injury. The illustrations on 
Plate 43 are very characteristic, and faithfully reproduce 
the conditions that I have often had occasion to observe 
in the living subject. The symptoms of the fracture are 

1 Deut. Zeitschr. f. Chir., Bd. lx, p. 193, 1901. 

2 For a review of the recent literature on fracture of the coronoid 
process see Progressive Medicine, for December, 1902. 

14 



210 FRACTURES AND DISLOCATIONS. 

very apparent, and the diagnosis never presents any diffi- 
culties. On the other hand, the injury at the elbow-joint 
consisting in dislocation of the radius is often overlooked ; 
by careful study of the introductory remarks this error 



Fig. 91 a. Fig. 91 b. 

Figs. 91 a and 91 b. — Fracture of the ulna. Operative reduction. 
Bone suture. Skiagraph. Spathmann, forty-nine years of age, fell 
from a wagon and was run over. Fracture of the lower half of the 
ulna with marked displacement of the fragments. Vain attempts at 
reduction under anesthesia; the deformity persisted (Fig. 91a), hence 
operative exposure, replacement, and bone suture (Fig. 915). Good 
recovery. [This illustration is a good example of a marked separation 
of the fragments when only one bone in the forearm is broken. — Ed.] 

may be avoided. The displacement of the fragment is so 
great, and the consequent shortening of the ulna so marked, 
that the radius must necessarily be either fractured or dis- 
located. If the surgeon will examine the elbow-joint, he 
will miss the head of the radius from its normal position. 



FRACTURES OF THE UPPER EXTREMITY. 211 

and find it either on the external condyle or on the ante- 
rior surface of the joint. The prognosis is favorable, 
providing the correct diagnosis has been made early, for 
reduction, as a rule, presents no particular difficulties if it 
is performed under anesthesia. The position of the frag- 
ments is corrected by vigorous traction on the forearm, 
after which the forearm is flexed and direct pressure ap- 
plied to the head of the radius. The head of the radius 
sometimes manifests a tendency to repeated luxation, espe- 
cially subluxation forward. It is, therefore, wise to dress 
the limb with the forearm at least at a right angle and in 
supination, and to add a soft pad in the bend of the elbow 
to produce moderate pressure on the head of the radius. 
[The position of acute flexion I found most satisfactory in 
these cases. — Ed.] 

In old cases of this kind osteotomy at the seat of fracture, 
and arthrotomy to effect reduction of the head of the radius, 
or resection of that bonv prominence may be required. 

(d) Fracture of the Shaft of the Ulna.— When the 
arm is put forth to guard against a fall, so that the fore- 
arm strikes the ground with the elbow-joint flexed ; or if 
the arm is raised to ward off a blow, the bone that suffers 
most is the ulna, which is often broken in one of these 
two ways. Such fractures are direct, and may be correctly 
termed " parrying fractures." The fracture rarely results 
from indirect violence. 

The diagnosis is readily made, owing to the superficial 
position of the ulna, which enables one to determine with- 
out difficulty the presence of abnormal mobility and crepi- 
tation. Treatment is the same as that of fracture of 
both bones of the forearm ; if the radius is intact, the dis- 
location is rarely very marked. 

(e) Fracture of the Styloid Process of the Ulna.— 
This is rare by itself and easily detected by careful palpa- 
tion. Recovery is apt to leave a false joint. For further 
discussion of this fracture see the section on Typical Frac- 
ture of the Lower Radial Epiphysis. 



212 



FRACTURES AND DISLOCATIONS. 



(C) Fractures of the Radius 

(a) Fracture of the Head of the Radius. — The 
symptoms are obviously those of an articular injury and 
the accident is without doubt often regarded as simple contu- 
sion or distortion of the joint. The fracture is completely 
intra-articular, and may be complete or incomplete (fissure- 
fracture, infraction). In the latter case the diagnosis is, 
of course, very difficult, and cannot be positively made. 

Complete fractures may 
be recognizable if the 
head of the radius is mov- 
able by itself and crepita- 
tion is produced, but this 
is not always the case. It 
often happens that the 
movement of the head 
during supination and 
pronation is not inter- 
fered with. Pain is of 
course localized to the 
region of the head of the 
radius. 

The fracture may be 
produced by direct, but 
more frequently by in- 
direct, violence, such as 
a fall on the hand with 
the elbow in extension or 
flexion, a piece being 
broken out of the head 
of the radius at the eminentia capitata — so-called chisel- 
fracture. 

Treatment. — As we have no means of directly influ- 
encing the position of the fragment, recovery often leaves 
considerable deformity. In the dressing, the elbow- and 
wrist-joints are of course to be placed at rest, and direct 




Fig. 92. Fig. 93. 

Figs. 92 and 93.— Fracture of the 
head of the radius in a woman 
twenty-eight years old, produced by 
a fall on the outstretched hand. 
The elbow-joint forms an obtuse an- 
gle. Pronation difficult. The head 
of the radius projects. Eesection. 
Recovery (1889). The fragment was 
united to the bone in a position of 
dislocation. 



FRACTURES OF THE UPPER EXTREMITY. 213 

pressure may be applied to the head of the radius. But 
in spite of every form of treatment indicated for joint- 
fractures, considerable stiffness of the elbow-joint may 
remain, and later make it necessary to resect the head of 
the radius. The radial nerve is sometimes injured in this 
fracture. 

Fracture of the neck of the radius — that is, below the 
head — is very rare. The chief symptom is a failure of 
the head to move with the bone in pronation and supina- 
tion ; a bony prominence may be felt at the seat of 
fracture. The treatment is the same as for the last variety. 

Traumatic epiphyseal separation at the upper end of 
the radius is extremely rare, and is of course only observed 
in children (see Plate* 41, Fig. 3). 

(b) Fracture of the Shaft of the Radius. — The 
rarity of fracture of the shaft of the radius alone forms a 
striking contrast to the frequency of the corresponding 
accidents in the ulna. The fracture may be direct or indi- 
rect. The symptoms are obvious and the diagnosis presents 
no difficulties. For the deformity and treatment, compare 
the paragraph on Fractures of the Forearm (page 196). 

(c) Fracture of the Lower Radial Epiphysis (Colles' 
Fracture) (Plates 44, 45, 46, and 47). — This is a very 
common fracture and of the greatest practical importance. 
It is justly called a typical one, because the symptoms are 
exceedingly characteristic and, with slight variations, 
appear constantly in every case. Our knowledge of the 
most important factors in its production has recently been 
greatly enriched through the agency of the Rontgen rays. 

Fractures of the lower end of the radius include the 
following : 

1. True epiphyseal separation (see under d, on page 
226). 

2. Incomplete fractures or fissured fractures, so-called 
typical contusions. They rarely occur by themselves, 
being usually combined with fracture. 

3. Complete fractures, which may be either transverse or 



214 FRAbTURES AXD DISLOCATIONS. 

PLATE 44. 

Typical Fracture of the Lower Radial Epiphysis. — Fig. 1. — 
Anatomic specimen showing a longitudinal section of the left arm with 
fracture of the lower radial epiphysis. The line of section goes through 
the radius and carpus, the third metacarpal bone, and the phalanges 
of the middle linger. The typical displacement of the fragment is 
seen: the axis of the radius and hand is interrupted by small, obliquely 
placed fragments, and simulates the appearance of a bayonet. The 
end of the upper fragment forms a prominence on the volar surface. 
corresponding to which an angular depression is found on the dorsal 
surface. 

Fig. 2. — The same fracture in the living subject. Copied from a 
photograph. Left arm. inner view. The typical deformity is at once 
recognized, consisting of a prominence on the volar surface formed 
by the lower extremity of the bones of the forearm. 

oblique. A transverse fracture involves the entire width 
and thickness of the bone, and therefore belongs to the 
class of supracondylar fractures. The line of fracture is 
usually found about 1.5 to 2 cm. above the lower articular 
-urface. at the point where the compact bone of the diaphy- 
sis is replaced by the abundant spongy outgrowth of the 
articular extremity. The boundary-line between these two 
sections, for anatomic and mechanical reasons, is very 
liable to fracture. The length of the epiphyseal fragment 
varies between 5 and 40 mm. The line of fracture is 
usually nearer the articular surface on one side than on the 
other, depending on the mode of production of the fracture. 
Multiple fractures at this point are much more common 
than was formerly supposed, especially the form known as 
a Y-fraeture, extending into the joint. 

In addition to these transverse, or somewhat oblique in- 
complete fractures, we have oblique fractures which do not 
involve the entire width and thickness of the bone. A 
fragment of variable size is split off from the styloid pro- 
cess of the radius, usually together with the dorsal border 
of the articular surface. These fractures are rarer than 
was formerly supposed. 



*• 
^ 



s. 




d.. 



^ 

•^ 




FRACTURES OF THE UPPER EXTREMITY. 



215 



Oblique fractures running from the dorsum downward 
into the articular surface also occur ; the bones exhibit an 
obstinate tendency to deformity and the diagnosis is less 
favorable on account of the direct injury to the joint. In- 
vestigations were recently made in Professor Oberst' s hos- 






W& 



Fig. 94 a and b. — Common forms of com- 
plete transverse or oblique fracture. 



Fig. 95.— Multiple frac- 
ture (Y-fracture) ; a com- 
paratively common form. 





b. 





m^ 



Fig. 96 a, b, and c. — Partial fractures of the lower articular extremity 

of the radius. 



pital by Dr. Kahleyss, and published in the Deutsche 
Zeitschr. f. Chir., vol. xlv ? page 531. The results of these 
investigations are peculiarly interesting because the fractures 
were carefully examined with the Rontgen rays. Figures 
94 ? 95, and 96 represent the varieties most frequently 
observed by Kahleyss among 60 cases. 



216 FRACTURES AND DISLOCATIONS. 

[The most recent and elaborate contribution to fractures 
of the lower end of the radius, with illustrations and liter- 
ature, is by Rosenbach, from the polyclinic of Gottingen. 1 
—Ed.] 

Involvement of the lower end of the ulna in these frac- 
tures is very common. Fracture of the styloid process of 
the ulna constitutes the most frequent complication of a 
typical fracture of the radial epiphysis ; Kahleyss found it 
present in 47 out of 60 cases, or in 78^. We may, 
therefore, lay down the rule that in radius fractures pre- 
senting marked deformity, fracture of the styloid process 
of the ulna is rarely absent. Sometimes there is only a 
fissured fracture of the process, gaping wide on the free 
ulnar side, but still attached to the radius. 

[In numerous X-ray negatives and illustrations of the 
literature of fractures of the lower end of the radius, I 
have observed but rarely a fracture of the lower end of the 
ulna. Scudder also considers the lesion rare, but states 
that a fracture of the styloid process of the ulna occurs in 
about 50 f to 65^ of all cases. — Ed.] 

The cause of fracture of the lower end of the radius 
in almost every case is a fall on the volar side (palm) 
of the hand. The first effect is overextension or ex- 
cessive dorsal flexion, which is resisted by the robust mass 
of ligaments on the flexor surface of the wrist (ligamentum 
carpi volare) ; if the force is great enough and the over- 
extension is continued, this ligament, instead of giving way, 
transmits the strain to the lower end of the radius with the 
production of a fracture at the spot referred to. It follows 
from this explanation that the fracture is one by muscular 
action, but at the same time the weight of the falling body 
and the resistance of the ground together produce a direct 
blow on the end of the radius ; and when the hand is over- 
extended, the upper row of carpal bones is forced against 
the dorsal, overhanging edge of the lower end of the 

1 Archiv f. klin. Chir., Bd. lxvi, 1902, p. 993. 



FRACTURES OF THE UPPER EXTREMITY. 217 

radius : hence the fracture is also produced by compression 
of the bone in its long axis. Whether the fracture be due 
to muscular action or to a direct blow, and it is probable 
that both factors are present in most cases, the lower frag- 
ment is always displaced toward the dorsum. 

If the fracture has been produced by a fall on the 
dorsum of the hand, — a mechanism which, although rare, 
has been observed, — the peripheral fragment is usually 
displaced toward the volar, instead of toward the dorsal, 
surface of the wrist. 

The symptoms of this fracture must be determined by 
accurate examination, beginning with a most careful in- 
spection. The surgeon sits directly opposite the patient, 
and the latter, after baring his forearms, places both hands 
together in a symmetric posture. 

If there is a fracture, inspection from in front will 
yield the following result : The styloid process of the ulna 
is more prominent than on the sound side (see Plate 44, 
Figs. 1 and 2) ; in the carpal region the hand is displaced 
toward the radius ; if the axis is marked along the middle 
of the forearm on each side, the line on the sound side will 
coincide approximately with the median line of the middle 
finger, but on the injured side it will be found a little 
nearer the ulna. The region of the styloid processes 
appears broader than normal. These symptoms are all 
due to the radial displacement of the peripheral fragment. 

The limb is next inspected from the side, preferably the 
radial side. In a normal limb the lower end of the fore- 
arm in pronation presents, on the radial side, a gentle 
curve, convex on the dorsal and concave on the volar side. 
In a broken arm the curve usually presents the opposite 
conditions; there is an abnormal prominence on the flexor 
surface and a slight angular depression on the dorsal sur- 
face. If the longitudinal axis of the forearm is traced on 
the skin with a blue pencil, the line on the normal side 
will cross the carpal region if the arm is held straight, but 
on the injured side this line is interrupted at a point cor- 



218 FRACTURES AND DISLOCATIONS. 

PLATE 45. 

Typical Fracture of the Lower End of the Radius (Colles' 
Fracture). — Fig. 1. — Anatomic specimen. Section of an old typical 
fracture of the lower end of the radius, united with considerable de- 
formity. Left radius seen from the radial side of the pronated hand. 
(See Plate 44. ) Corresponding to the seat of fracture, a prominence is 
seen on the volar side and an angular depression on the dorsal side. 
There has been a rearrangement of the trabecular in the spongy bone ; 
the original cortex (dorsal) is barely made out as a narrow zone 
within the spongy bone. The lower articular surface, as a result of 
the displacement, forms an acute angle with the longitudinal axis of 
the shaft of the radius. 

Fig. 2. — This specimen is analogous to that shown in figure 1 ; 
also a section of the left radius. The deformity is somewhat less 
marked and the prominences, which are useless from a mechanical 
standpoint, have evidently become absorbed in the course of years. 
The remains of old compact bone are recognized as a spongy tract. 
The articular surface forms an oblique angle with the longitudinal 
axis of the bone. The specimen is a sagittal section of the radius 
shown in figure 5, Plate 45. 

Fig. 3. — The fracture under discussion was produced artificially 
and the specimen then dissected. Eight hand, dorsal view. We see 
the displacement of the lower epiphyseal fragment and of the entire 
hand toward the radius, causing an abnormal prominence of the styloid 
process of the ulna. 

Fig. 4. — Typical fracture of the lower radial epiphysis in the living 
subject. Dorsal surface of the right hand. The radial displacement 
of the hand and the prominence of the st} T loid process of the ulna are 
well shown. 

Fig. 5. — Bones from the same forearm (left), in pronation ; seen 
from the volar surface. Typical fracture of the radius (compare with 
the section of this radius in Fig. 2 ) . The ulna presents a high degree 
of arthritis deformans (not the bony tuberosities which are eburnated 
and show smooth surfaces) at the articular circumference (lower radio- 
ulnar articulation) ; it is possible that the ulna was also injured at 
this place in this fracture. 



responding to the radial epiphysis where the line forms a 
shoulder. When the hand is held straight, this line 







B 



Tab AS. 



Full. 




tiff.. 



Fiij.S. 




Ficf.J. 






t 



I f I 
I 'A 



Fig. 4 . 

Lith.Anst R ReichhoM Mum-hen. 



FRACTURES OF THE UPPER EXTREMITY. 219 

is bent in the shape of a bayonet and constitutes the typi- 
cal symptom of this fracture. This deformity is best ex- 
plained by assuming a continued action of the force at the 
time of injury. As soon as the fracture has been pro- 
duced, the weight of the falling body must continue to 
exert its influence until the end of the upper fragment 
touches the ground. Muscular action may have some- 
thing to do with the production of this typical deformity, 
but the chief cause lies in the external force itself. The 
epiphyseal fragment is displaced upward and comes into 
partial supination, while the shaft of the radius is pro- 
nated. The connection between the lower ends of the 
radius and the ulna exerts some influence on the character 
of the deformity, which is produced in the following man- 
ner : As long as the ligamentous connection between the 
two bones remains intact the lower end of the ulna ap- 
proximately forms the pivot around which the radius 
moves; but it has already been stated that the styloid 
process of the ulna is very often split off, especially by a 
force acting in the direction of the radius. 

The other symptoms of fracture are not always very 
evident. Abnormal mobility is, as a rule, difficult to 
demonstrate. To elicit it, the surgeon must seize the 
epiphyseal fragment firmly with his fingers and brace 
the injured arm against his own body; it is, how- 
ever, unnecessary to establish the presence of this symp- 
tom. The same is true of crepitation, though a char- 
acteristic cracking and rubbing is quite often felt. The 
finding of a painful point is much more important. If 
the articular region is carefully palpated on the radial 
side, the line of the joint and the styloid process in the 
radius will be free from pain in a transverse fracture, 
while 1 to 2 cm. above that point typical fracture-pain 
will be elicited. The results obtained by inspection are 
thus confirmed by palpation. The surgeon feels the ab- 
normal bony prominence on the volar surface and the an- 
gular depression of the radius on the dorsal surface. 



220 FRACTURES AND DISLOCATIONS. 

PLATES 46 and 47. 

Differential Diagnosis of Fractures and Dislocations of the 
Wrist. — Figs. 1 and 1 a. — Infraction or greenstick fracture of both 
bones of the forearm, near their extremities. Marked .dorsal angular 
deformity of the peripheral fragment. (Hans Muller, five years, 
Greifswald, 1894. ) 

Figs. 2 and 2 a. — Fracture of the lower end of the radius, seen 
from the side. Typical deformity. (Fran Langhof, Greifswald, 
1887.) (See Plate 44, Fig. 2.) 

Figs. 3 and 3 a. — Dorsal dislocation of the hand on the radio-carpal 
articulation. Artificial. 

Figs. 4 and 4 a. — Dorsal dislocation of the hand at the carpo-meta- 
carpal joints of the four fingers. Seen from the dorso-ulnar direction. 
(Artificial. ) 



The diagnosis is made, as a rule, by accurate inspec- 
tion and comparison with the sound side ; it is important 
for the differential diagnosis to determine the position of 
the styloid processes in relation to the painful point or seat 
of fracture. There can never be any difficulty in distin- 
guishing between fracture and the exceedingly rare dislo- 
cations of the hand. On the other hand, it may be diffi- 
cult, when there is much swelling and the pain is great, to 
distinguish an infraction or impacted fracture from a so- 
called typical contusion of the lower radial epiphysis. In 
doubtful cases the question may eventually have to be 
decided by means of the Rontgen rays. 

The prognosis of this fracture depends on the treat- 
ment. If it is correctly carried out, complete functional 
recovery is possible. I have in my possession a specimen 
of a recently united fracture from an elderly woman who 
died of pneumonia soon after the bone had healed. In 
this specimen the union is bony, and not the slightest 
degree of deformity can be detected. 

Treatment. — The fracture is reduced by direct pressure 
while the hand is in forced flexion, and by traction. It is 
best performed under anesthesia. It is desirable to have 



220 FRACTURES A Kit DISLOCATIONS. 




doubtful case 8 J* quotm ] 


nay eventually 


have to be 


Tlie prognosis of this frac 


;;!: ,: ;-Efi 


>n the treat- 
te functional 

healed. In 
he slightest 



Treatment.— 'I'lic fracture i- reduced by direct pressure 
while the hand is in forced flexion, and by traction. It is 
■est pcrfnmicd under anesthesia. It is desirable to have 






FE AC TUBES OF THE UPPER EXTREMITY. 221 

two assistants, especially while the dressing is applied. 
One of the assistants takes the thumb in one hand and the 
other fingers in the other, as shown in .figure 98. This 
enables the surgeon to apply the dressing in the proper 
way. If it is desired to protect the side of the little finger 




Fig. 97. — Old fracture of the radius with pronounced and typical 
displacement. Rontgen-ray picture. (Friedrich Schutt, forty -eight 
years. ) 

from the pressure of the bandage, it may be left out, as 
shown in figure 99, so as to prevent the bandage from 
becoming too tight at this point. If the fracture is well 
reduced, there is, as a rule, no tendency for the deformity 
to recur. 

[In reducing a fracture of the lower end of the radius 



222 



FRACTURES AND DISLOCATIONS. 



I have found, both in recent and old injuries, that forced 
overextension of the hand and lower fragment of the radius 




Fig. 98. — Showing assistance in dressing a typical fracture of the 
lower end of the radius (see Fig. 99). 



breaks up the impaction, and then by the forced flexion 
and direct pressure, associated with full traction, the frag- 
ment is more easily brought to the correct position. It is 

a very important point 
(one frequently neg- 
lected) that the impac- 
tions of the fragments 
should be completely 
broken up by this ma- 
nipulation before the 
attempt is made at re- 
duction. — Ed.] 

The dressing should 
include the entire fore- 
arm, the wrist-joint, and 
the metacarpal region ; 
the elbow-joint need 
not be, and the fingers must not be fixed. Forced inac- 
tion of the fingers in many persons is apt to produce a 
troublesome rigidity that can only be removed by pain- 




Fig. 99. — Showing another method 
of seizing the fingers for the purpose of 
applying extension (see Fig. 98). 



FRACTURES OF THE UPPER EXTREMITY, 223 

ful treatment with massage and passive movements, and 
may even persist to a greater or less extent. 

As the short lower fragment can only be influenced 
through the hand, the latter must be so placed as to insure 
correct position of the lower fragment. The hand must 
be flexed with a slight deviation toward the ulnar side ; 
this will prevent recurrence of the deformity. In effect- 
ing reduction and applying the dressing it is not to be for- 
gotten that the hand, including the fragment, must be dis- 




Fig. 100. — Showing the application of a plaster-of -Paris splint. 
After reduction has been effected, the arm is placed on the patient's 
thigh, the flexed wrist lying on the knee. (Beely's method.) 

placed toward the ulna as a whole, otherwise an unsightly 
prominence of the styloid process of the ulna will remain. 
Whether these indications are met by one method or by 
another is of no importance. A Beely's plaster-of-Paris 
splint (Fig. 100) is very useful, or a small curved splint, 
after Schede (Fig. 101), which fixes the hand in the de- 
sired position may be used. In improvising a splint from 
a piece of pasteboard or board, ulnar flexion of the hand 



224 



FRACTURES AND DISLOCATIONS. 



can be effected by giving the splint the well-known pistol 
shape. A soft pad should be placed under the end of the 
upper fragment of the radius so as to push it upward • the 
epiphyseal fragment, being left unsupported, tends to drop 
by its own weight. Besides similar dressings, which all 
attain the same object in somewhat different ways (Braatz, 
Kolliker, and others), a method has recently been pro- 
posed by Storp in place of the use of a simple sling, as 
recommended by Petersen and earlier surgeons. I am 




Fig. 101. — Position of the hand on a volar splint, after Schede, with 
the splint itself. The direction in which the turns of the bandage are 
best applied is indicated by the arrows. 



tempted to propose the name " suspension cuff-dressing" 
(Fig. 102). After repeated trials I am convinced of its 
great value. 

After the fracture has been fully reduced, if necessary 
under anesthesia, the hand is brought into extreme ulnar- 
volar flexion ; the lower extremity of the forearm, as far 
as the styloid processes, is then wrapped with several 
turns of a strip of adhesive plaster about 10 cm. wide. 
By means of another strip a loose dorsal fold is added to 
which the sling is attached. I arrange this fold so as to 



FEACTCBES OF THE UPPER EXTREMITY. 



225 



bring it over the middle of the radius on the dorsal side, 
so that when the hand is suspended, it hangs down in 
ulnar-volar flex- 
ion. Storp has 
used this method 
iu 108 cases and 
found it successful 
in all but 4, in 
which the deform- 
ity returned. In 
such cases a splint 
is indispensable. 
I have used the 
method so far in 5 
cases and found it 
exceedingly use- 
ful. 

In severe cases 
it is advisable to 
fix the arm in su- 
pination. Fortius 




Fig. 102. — Suspensory cuff-dressing of a typical 
fracture of the lower end of the radius. 




Fig. 103. — Roser's method, with the arm in full supination. The 
patient looks into the hollow of his hand. 

purpose the best dressing is that devised by Roser (Fig. 
103), which appears to me somewhat bulky and circunv- 
15 



226 



FRACTURES AND DISLOCATIONS. 



stantial — for most cases of this fracture can just as well 
be dressed in pronation. The pad is so arranged on a 
splint that the wrist and radial epiphysis — ?. e., the frag- 
ment — are flexed toward the volar surface (Fig. 103). 

The surgeon should never forget that he is dealing with 
a joint-fracture. The dressing should be frequently 
changed (if a dressing has been applied) ; massage and 
active movements are indicated early. It is undoubtedly 

better to get a well-united 
fracture with good move- 
ment, even with some de- 
formity, than one without 
deformity, but with serious 
loss of function at the wrist- 
joint. 

If the fracture is compli- 
cated by fracture of the sty- 
loid process of the ulna, — 
in other words, if both bones 
of the forearm are broken 
at their lower extremity 
(Fig. 104), — the radio-ulnar 
articulation and the wrist- 
joint are very apt to become 
involved also (see Arthritis 
Deformans, Plate 45, Fig. 
5). This fracture is in the 
main to be treated on the 
same principles. In a few 
cases resection of the styloid process was later found neces- 
sary to improve the movement. 

[In the original German the term Colles* fracture is not 
used. This name, however, is too intimately connected 
with fractures of the lower end of the radius to be omitted 
from any English text. — Ed.] 

(d) True epiphyseal separation of the lower end of 
the radius is comparatively frequent in youthful individ- 




Fig. 104. — Typical fracture of 
the radius (united without de- 
formity), with fracture of the 
styloid process of the ulna. Ront- 
gen-ray picture. 



FRACTURES OF THE UPPER EXTREMITY. 227 

uals. The symptoms and treatment are exactly the same 
as in typical fracture of the lower end of the radius in 
adults (see Plate 51, Fig. 5). 

(D) Dislocation at the Lower Articulation of 
the Ulna 

In spite of the weakness of the ligamentary apparatus 
and the frequency with which the part is exposed to ex- 
ternal violence, this luxation is extremely rare. The 
lower articular extremity of the ulna may be dislocated 
backward (dorsal dislocation) directly, by a fall or by ex- 
cessive pronation ; or forward (volar dislocation) either 
directly or by excessive supination. The symptoms are 
determined by careful palpation. Subluxation of this 
joint, produced by wringing clothes, is met with in wash- 
erwomen. The treatment is based on general principles. 



7. WRIST=JOINT 

Dislocation of the hand at the radiocarpal joint is ex- 
ceedingly rare ; although this diagnosis has frequently 
been made in former times, it is now generally conceded 
that the great majority of cases so reported were cases of 
typical fracture of the lower end of the radius. Authentic 
instances of true luxation can be counted, — they number 
about 30, — and, besides, part of them were complicated 
by fracture of the styloid process of the radius (Plates 46 
and 47, Fig. 3). 

The dislocation may be backward (dorsal) or forward 
(volar) ; the carpus rests against the dorsal or the volar 
side of the articular extremities of the bones of the arm. 
The injury is produced by a fall on the outstretched hand 
in excessive dorsal (dorsal dislocation) or volar (volar dis- 
location) flexion. The diagnosis is made by careful palpa- 
tion ; reduction is effected by traction and direct pressure. 



228 



FRACTURES AND DISLOCATIONS. 



PLATE 47 a. 
Skiagraph of a Normal Adult Wrist=joint. Anterior View. 



Os metacaijiale / ~ 
Os multanfiiUum minus 
Os maUangulam ma/us 

Os naoicutare-- - 
Processus stylvideus radO- 




Processus styloldcus ulnae 



Radius- - 



8. HAND AND FINGERS 

(A) Fractures 

Fractures of the carpal bones are rare, and occur usually 
in combination with severe lacerated or contused wounds 
of the soft parts by which they are covered. The degree 
of the injury depends on the severity of the complicating 
lesion. 

Fractures of the metacarpal bones are not so uncommon, 
and are produced by a fall on the dorsum of the hand, by 
a direct blow, etc. Abnormal mobility and crepitation 
can usually be demonstrated, along with intense pain at 



Tab. 47 a. 




FRACTURES OF THE UPPER EXTREMITY. 229 

the seat of fracture. Deformity is usually absent, since 
the bones practically act as splints to one another. The 
treatment accordingly is simple. If an ordinary dressing 
and carrying the hand in a sling do not suffice, direct 
pressure, either on one or both sides, by means of short 
splints or rubber tubes, may be applied to keep the frag- 
ments in position. In compound fractures due to severe 




Fig. 105. — Severe compound fracture of the second and third meta- 
carpal bones; marked displacement of the fragments. Skiagraph taken 
through the bandage. 

external violence, operative intervention is sometimes indi- 
cated (see Fig. 105). It is well to begin massage and pas- 
sive movements of the fingers early in the treatment. 

[In this country we observe quite frequently fractures 
of the third and fourth metacarpal bone from a blow upon 
the knuckle. It is not an infrequent boxing or prize- 
fighting injury. In the cases which I have observed there 



230 



FRACTURES AND DISLOCATIONS. 



PLATE 47 b. 
Skiagraph of a Normal Adult Wrist=joint ; Lateral View. 



Os mct.axar[uile> I 

Os median guLuni, minus 
Os rruUtangiiLuru majns 

Os naoLculare - 
Os /lisiforme- 

Radius 




Os rrcctacarpxxle H 
Os metcucarpxile, HI 

- Os cafiitttturrv 
Os hamxilwrv 
*)--Os triqiuiruirh 

Os lunaXuirh 

Proc. stylouleus ulnae. 
Ulna, 



has been a deformity, and I should recommend that the 
fracture be dressed with a pad in the palm of the hand to 
preserve the palmar arch, or the fracture be dressed with 
a roll of bandage in the palm of the hand over which the 
fingers and thumb are flexed and held in position by a 
bandage. This is recommended and illustrated by Scudder 
(foe. cit, p. 236).— Ed.] 

Fractures of the phalanges are usually produced by 
direct violence, but may also result indirectly by a force 
acting in the longitudinal direction of the phalanges ; we 
thus occasionally meet with longitudinal fractures. They 
are also said to be produced in the distal phalanges by the 



Tab. 47 b. 




FRACTURES OF THE UPPER EXTREMITY. 231 

pull of the extensor tendons in forced flexion of the fingers. 
Owing to the exposed position of the parts, the diagnosis 
and treatment (by means of small padded splints) present 
no difficulties whatever. 

(B) Dislocations 

(a) Intercarpal dislocation, or dislocation altering 
the relative positions of the two rows of carpal bones, is 




Fig. 106. — Showing the same hand as in figure 105, after operative 
correction of the deformity. Skiagraph taken in the same way as that 
of figure 105. 

exceedingly rare. Dislocation of a single carpal bone is 
somew T hat more frequent. The dislocated bone forms a 
prominence, the position and shape of which determine the 
diagnosis, when it can be made. 

(b) Dislocation at the carpo-metacarpal joints is 
also a rare accident. It is met with most frequently at the 
carpo-metacarpal joint of the thumb. The first metacar- 



232 



FRACTURES AND DISLOCATIONS. 



pal bone may be displaced backward or, more rarely, for- 
ward, and finally to the radial side. The diagnosis is made 
by the abnormal prominence and the direction of the meta- 
carpal shaft. Reduction is effected by traction and direct 
pressure (see Plate 46 and Plate 47, Fig. 4). 




Fig. 107. — Skiagraph of a typical dislocation of the thumb in a 
youthful individual. The epiphyseal lines are visible. (Obtained by 
the courtesy of Geheimrat Trendelenburg in Leipzig.) 

(c) Dislocation of the metacarpal-phalangeal joints 
occurs rarely at the second, third, fourth, and fifth fingers, 
but is comparatively frequent at the thumb, and of great 
practical importance. 



FRACTURES OF THE UPPER EXTREMITY. 233 

Dislocation of the thumb in its typical form is always 
a backward dislocation ; i. e. y the base of the first phalanx 
slips back over the capitellum of the first metacarpal bone. 
We distinguish complete and incomplete dislocation of the 
thumb, depending on whether the two articular surfaces 
are partially in contact or completely out of contact. 

This dislocation can easily be produced artificially in the 
cadaver by overextension (maximal dorsal flexion) and 
forcible displacement of the dislocated first phalanx toward 
the wrist-joint. If after this the thumb, by a slight 
movement of flexion, is brought into an erect position, all 
the characteristic symptoms of a typical dislocation of the 
thumb will be produced. I have even observed the inter- 
position of soft parts in such an artificially produced dis- 
location, making it impossible to reduce the luxation. 
This will be referred to again later on. The chief feature, 
both in artificial and in accidental dislocation of the thumb 
in the living subject, is fixation of the dislocated member. 
This is due to the traction of the soft parts entering into 
the composition of and surrounding the joint. The lateral 
ligaments often remain intact, and a number of robust 
muscles and tendons bring about fixation by wrapping 
themselves about the head of the first metacarpal bone. 
This constitutes an obstacle in ignorant attempts to effect 
reduction by simple traction ; the more we pull on the 
thumb, the more closely the tendons and muscles will hug 
the neck of the metacarpal bone and prevent the thumb 
from slipping into place. This is the so-called button- 
hole mechanism (see Plate 48, Fig. 1, and Fig. 109). 

Symptoms, — The lines formed by the thumb and first 
metacarpal bone suggest a bayonet; the marked promi- 
nence of the head of the first metacarpal bone on the 
volar surface and the abnormal direction of the first pha- 
lanx, combined with a peculiar rigid fixation of the parts, 
point to the correct diagnosis. 

Just as in all other hinge-joints, redaction must be per- 
formed without employing force. After overextension of 



234 



FRACTURES AND DISLOCATIONS. 



PLATE 48. 

Typical Dislocation of the Thumb. — Fig. 1. — Anatomic speci- 
men of the right hand seen from the volar side. The base of the first 
phalanx is dislocated to the dorsal side of the head of the first meta- 
carpal bone ; the capitellum forms a marked prominence ; the capsule 
is torn on its flexor surface and displaced dorsally with the first pha- 
lanx. We will designate the two sides of the head of the metacarpal 
bones as the radial and the ulnar sides : On the ulnar side the adduc- 
tor pollicis and the tendon of the flexor pollicis longus are wrapped 
about the neck of the metacarpal bone, while on the radial side we 
find first the flexor pollicis brevis and then the abductor pollicis brevis. 
The capitellum has escaped from between these muscles as through a 
cleft ; the tendon of the flexor pollicis longus lies closest to the neck 
of the metacarpal bone and in the illustration is hidden behind the 
capitellum, coming into view again on the volar side of the first 
phalanx. 

Fig. 2. — Typical dislocation of the thumb in the living subject. 
Right hand, seen from the volar side. Figure 1 elucidates the charac- 
teristic deformity which is here shown. 



Flexor pollicis longus (ten do) 
Muse, adductor pollicis 



Phalanx I pollicis (basis) 

Capituluni metacarpi I 

Muse, flexor pollicis brevis 
Muse, abduc. pollicis brevis 




Fig. 108.— (Explanation of figure 1, Plate 48.) 



Ijib.tfH. 




Fig.2. 




Fiq.l. 



Liih. Anst E Reich hold . Munch en . 



FRACTURES OF THE UPPER EXTREMITY. 235 

the thumb, direct pressure is applied against the base of 




Fig. 109. — Improper attempt to effect reduction by simple traction. 
Every effort merely increases the fixation (button-hole mechanism). 

the first phalanx, and the thumb is pushed directly for- 
ward. As soon as more than half of the articular sur- 




Fig. 110. — Correct method of reduction; the thumb is overextended 
and pushed forward. 

faces are brought into normal contact, flexion becomes 



236 



FRACTURES AND DISLOCATIONS. 




Fig. 111. — Eeduction prevented by 
the interposition of the capsule. 



possible and the thumb slips into place. The importance 
of correctly performing this manoeuver should be empha- 
sized, but it does not insure successful reduction. 

A frequent obstacle to 
reduction is interposition 
of the capsule, or, some- 
times, of a sesamoid bone. 
In other cases attempts at 
reduction are frustrated by 
a peculiar behavior on the 
part of the tendon of the 
flexor pollicis longus, which 
I have observed both in the 
living subject and on the cadaver when the dislocation, 
had been produced artificially. The tendon surrounds 
the neck of the first 
metacarpal bone ; if the 
articular surface of the 
capitellum is greatly 
thickened on its ulnar 
side, as sometimes hap- 
pens, the tendon may 
catch on this thickened 

rim and form an insurmountable obstacle to reduction. 
The condition may sometimes be recognized by the thumb 

being slightly rotated and 
inclined toward the ulnar 
side and the tendon may 
sometimes, but not by any 
means always, be disen- 
gaged by increasing this 
inclination toward the ul- 
nar side. 

In exceptional cases it 
may happen that during the attempts at reduction, espe- 
cially if traction is improperly applied to the thumb, the 
capsule and the external sesamoid bone become completely 




Fig. 112. — Reduction is prevented by 
the interposition of the sesamoid bone. 




Fig. 113. — Reduction is prevented 
by the tendon of the flexor pollicis 
longus catching on the head of the 
first metacarpal bone. 



FPACTUBES OF THE UPPER EXTEE3IITY. 



237 




Fig. 114. — Backward dislocation of 
the second phalanx of the little finger 
in a boy fifteen years old. (Binschuss, 
1896.) The dislocation was reduced 
and a good result followed. 



turned over and interposed between the articular extremi 
ties in the inverse direction (luxatio complexa). 

If reduction is found 
impossible, arthrotomy 
must at once be per- 
formed. In all such 
cases I have succeeded, 
by cutting down on the 
prominence of the capi- 
tellum on the volar side 
and dissecting the tis- 
sues, in discovering the 
obstacle, and, after effect- 
ing reduction, have uni- 
formly obtained a good functional result. In old cases 
resection of the head of the metacarpal bone may become 

necessary. 

In regard to the symp- 
toms and treatment of volar 
or forward dislocation of the 
thumb, which is a very 
much rarer injury, there is 
little to add to the foregoing 
remarks except to advise 
an attentive study of Plate 
48. The diagnosis and treatment should present no diffi- 
culties. 

Dislocation at the metacarpo=phaIangeal joints of 




Fig. 115. — Section of the middle 
finger with dorsal dislocation of 
the second phalanx. 




Fig. 116. Fig. 117. 

Figs. 116 and 117. — Dorsal and volar dislocation of the distal phalanx. 

the second, third, fourth, and fifth fingers, like disloca- 
tion of the thumb, is usually dorsal. In this dislocation 



238 FRACTURES AND DISLOCATIONS. 

also interposition of the capsule has been observed. Occa- 
sionally the dislocated finger presents a lateral angular 
deformity. The injury is usually compound; reduction 
is effected by overextending the phalanx and pushing it 
forward. 

(d) Dislocation at the interphalangeal joints of 
the fingers is comparatively frequent, and is often reduced 
by the patient. The dislocation may be dorsal, volar, or 
lateral if the lateral ligaments are torn. It may occur in 
any one of the joints. The diagnosis and reduction present 
no difficulties. 



VII. FRACTURES AND DISLOCATIONS OF THE 
LOWER EXTREMITY 

The importance of injuries to the lower extremity is 
enhanced by the fact that they demand not only proper 
correction of the local injury, but also special attention to 
the patients general condition. In old persons, and in 
conditions of debility from overwork and other causes, it 
is important to avoid a prolonged confinement to bed 
(hypostatic pneumonia); The patients should be gotten 
up as soon as possible and allowed to move about with a 
well-fitting dressing. 



I. PELVIS. (Plate 49.) 

Solution of continuity in the bones of the pelvis usually 
implies the action of very considerable force. 1 The vic- 
tim usually has fallen from a great height or has been 
crushed by large and heavy objects, by a cave-in, etc. 
These accidents may produce fractures, or separation of 
the symphyses of the pelvic bones. The latter are even 

1 Professor Kichter has called attention to the fact that fractures of 
the pelvic ring occasionally occur in comparatively inconsiderable 
injuries. 



FRACTURES OF THE LOWER EXTREMITY. 239 

more rare than fractures, as their production presupposes 
laceration of the exceedingly robust ligaments at the sym- 
physis pubis and the sacro-iliac articulation. Separation 
of the Y-shaped cartilage in the acetabulum (see Plate 49, 
Fig. 2) is not possible except in connection with some 
other solution of continuity in the bones that enter into 
the formation of the pelvic ring. A positive diagnosis can 
be made only when the separation of the bones is compli- 
cated by marked displacement of the parts. Other cases, 
particularly those involving the sacro-iliac symphysis, pre- 
sent the symptoms of severe distortion which, taken together 
with a knowledge of the cause of the injury, will usually 
suffice to determine the nature of the lesion. The treat- 
ment is based on general principles. 

Fractures of the pelvis are divided clinically into two 
classes : one in which individual parts of the pelvis are 
fractured, and one in which the continuity of the pelvic 
ring is actually interrupted. 

The former class includes fracture of a portion of 
the innominate bone, fracture of the sacrum or coccyx, 
and fracture of the tuberosities of the ischium. The 
broken portions of the bone may sometimes be de- 
tected on direct examination by their abnormal mobility 
and, it may be, by the presence of crepitation and displace- 
ment. Accessory injuries are rarely present in these frac- 
tures. The treatment aims at securing union in as nearly 
a correct position as possible ; but even if deformities 
should result, they are of no practical significance. 

Fracture of the pelvic ring is a much more vital injury. 
In the first place, it requires a severe injury to interrupt 
the continuity of the pelvic ring ; and, in the second place, 
as a necessary corollary, accessory injuries are compara- 
tively common. Injury of the sciatic and other nerves, 
of the femoral vessels, of the bladder, and of the rectum 
are comparatively rare ; but an injury to the urethra in 
men is relatively common in fracture of the pelvis, and is 
of the highest practical importance. It manifests itself by 



240 FRACTURES AND DISLOCATIONS. 

PLATE 49. 

Fractures of the Pelvis.— Fig. 1.— Severe fractures of the pelvic 
ring, so-called double vertical fracture of Malgaigne, in an adult ; 
produced by being run over while he was lying on his back. In front, 
the pelvis has been fractured on each side of the symphysis pubis in 
the region of the parts surrounding the obturator foramen ; the central 
piece is accordingly completely separated. Posteriorly a second line 
of fracture is found at the base of the innominate bone, close to the 
sacro-iliac articulation, justifying the term double vertical fracture. 

Fig. 2. — Severe fracture of the pelvic ring through the acetabulum. 
(W. Kohn, male, fourteen years old, 1889. See explanation of Plate 
1, Fig. 1. ) The injury was produced by the cogwheels of a threshing 
machine. The fracture involved the left pubis and ischium, and led 
to separation of the Y-shaped cartilage in the acetabulum. There was 
also a large lacerated wound in the region of the left groin, exposing 
the femoral vessels, as in an anatomic preparation, and communicat- 
ing with a large wound-cavity between the adductor muscles. Within 
this wound-cavity the fracture in the bony rim of the obturator fora- 
men can be felt. The left thigh was somewhat adducted, the penis 
badly contused but the urethra intact ; normal urine flowed through 
the catheter. The patient succumbed to the severity of the injury. 

Fig. 3. — Fracture of the innominate bone (not a fracture of the 
pelvic ring). 

the discharge of blood from the urethra or the admixture 
of blood in the urine. The introduction of a catheter 
is necessary both for diagnostic and therapeutic purposes 
(permanent catheter). If catheterization is unsuccessful, 
there is imminent danger of the urine infiltrating the sur- 
rounding cellular tissues and leading to fatal consequences 
through gangrene and sepsis. Hence immediate and free 
incision from without, as in external urethrotomy, and, 
under certain circumstances, a high incision (suprapubic) 
and so-called retrograde catheterization may be justifiable. 
The latter operation should not be attempted without the 
facilities of a hospital ; but any physician may properly be 
expected to incise the cellular tissue surrounding the 
urethra and at least establish the diagnosis of a severe in- 
jury, so that the proper treatment may be instituted. 



TabAV. 




Fial 




Fig.?. 




FRACTURES OF THE LOWER EXTREMITY. 241 

[Most dangerous complications of fractures of the pelvis 
are rupture of the bladder and the urethra. These possi- 
bilities should always be borne in mind, and they demand 
immediate treatment. If possible the patient should be 
sent at once to a hospital, because the after-treatment is 
almost as important as the early operation. A rupture of 
the bladder demands an earlier operation than a rupture 
of the urethra. The early diagnosis and treatment of 
these injuries is a subject for a text-book on surgery, but it 
is not out of place here to urge the immediate search for 
these accompanying injuries in fractures of the pelvis. 
It is the experience of every large surgical clinic that these 
patients are frequently brought to to the hospital too late 
for successful surgical intervention. 1 — Ed.] 

Fractures of the pelvic ring present many varieties. 
Besides the injuries due to the action of the vertebral 
column and of the thigh on the pelvis, we have to deal 
chiefly with compression of the pelvis, either in its antero- 
posterior direction, — as when a man is run over, or has 
his horse fall on him when he is lying on his back, — or in 
the lateral diameter. The mechanism has been studied 
experimentally. If pressure acts in the antero-posterior 
diameter, the anterior wall of the pelvis is the first to give 
way, the lines of fracture passing through the upper and 
lower margin of the obturator foramen on both sides. 
This is followed by a separation of the sacro-iliac articu- 
lation or by fracture of the sacrum parallel to the joint. 
Lateral compression is also followed first by a fracture in 
the anterior wall, the pubic region, which is the weakest 
part of the ring ; the line traverses the obturator foramen. 
This is followed by fracture of the innominate bone, 
parallel to the sacro-iliac joint, providing that the liga- 
mentous apparatus of that joint remains intact. Thus 
one-half the pelvis may be fractured both in its anterior 

1 James F. Mitchell, Annals of Surgery, February, 1898, contributed 
a splendid article on pelvic fracture complicated by rupture of the 
bladder, with a collection of all the cases in the literature. — Ed. 
16 



242 FRACTURES AND DISLOCATIONS. 

and in its posterior wall at the same time ; i. e., the so- 
called double vertical fracture of Malgaigne is produced. 
Numerous other lines of fracture may be produced, if the 
pelvis is compressed in a diagonal diameter. In actual 
practice the injuries leading to fracture of the pelvis are, 
as a rule, so severe and of so manifold a character that the 
pelvis is fractured in many places, instead of presenting a 
typical fracture, such as has been described. At the 
autopsy fifteen or twenty, or even more, separate lines of 
fracture and cracks are generally found. 

In making the examination it is well to begin by at- 
tempting to compress the pelvis with the two hands applied 
to the crest of the ilium. If fracture is present, this will 
produce a violent pain at the seat of fracture, and may 
even in some cases elicit abnormal mobility and crepi- 
tation. 

The tuberosities and the ascending ramus of the ischium, 
the descending ramus of the pubis, and other accessible 
portions of the pelvis must always be carefully palpated 
and tested for sensitiveness. On the posterior surface the 
region of the posterior superior spines of the ilium, which 
is normally indicated by a slight depression, must be sub- 
jected to careful scrutiny and comparison with the other 
side. Sometimes rectal examination may yield valuable 
information. 

The prognosis depends on the extent of the accessory 
injuries. If there are none present, recovery may be ex- 
pected. 

Treatment. — The patient should be placed on a water- 
bed or a mattress stuifed with millet-chaff, or on a specially 
constructed surgical bed, as in fracture of a vertebra, so as 
to avoid moving him for the purpose of defecation. A 
circular bandage around the pelvis is often actually useful 
in itself, and is usually a comfort to the patient. In frac- 
ture of the acetabulum, passive movement of the hip-joint 
must be carried out during the course of the treatment. 

[In fractures of the pelvic ring confined to one side, I 



FRACTURES OF THE LOWER EXTREMITY. 



243 



have found that extension of the lower extremity on the 
affected side, especially if the thigh is well flexed, adds 
much to the comfort of the patient and reduces apparently 




Fig. 118. — Attitude in bed of a patient with fracture of the pelvis 
(Kurek, 1895), with a circular extension dressing. On the 14th of 
May, 1895, Kurek sustained a severe injury by the giving way of the 
floor of a barn loaded with about 25 tons of oats. The joists and 
other par^s of the woodwork fell on his left side. Great extravasation 
of blood in the region of the left hip and pelvis; pain elicited by 
lateral compression, with indistinct crepitation and abnormal mobility. 
The seat of greatest pain was in the region of the left sacro-iliac artic- 
ulation. The urine was voided spontaneously and was not mixed 
with blood. There was a large ecchymosis in the scrotum. The 
pelvis was dressed as shown in the illustration and the patient 
recovered. He was discharged on the 19th of July, 1895. The left 
innominate bone is about 2 cm. higher than the right. The region of 
the posterior superior spines of the ilium is thickened by new-for- 
mation of bone and still sensitive to pressure. Patient wore a circular 
plaster-of-Paris dressing when he was discharged. 



the resultant shortening of the limb. A Smith's anterior 
splint provides the most convenient method of extension. 
In four cases of fracture of the pelvic ring I have observed a 



244 FRACTURES AND DISLOCATIONS. 

moderate degree of shortening of the limb on the affected 
side due to the elevation of the pelvis. The leg is also 
slightly adducted. If not carefully examined, the de- 
formity might be mistaken for an old fracture of the neck 
of the femur. The functional result is always good. 
Fracture of the wing of the iliac bone is not infrequently 
associated with extensive hemorrhage and the formation 
of a large hematoma. In one instance I found it neces- 
sary to make an incision and pack with gauze the bleeding 
fractured surface of the cancellous bone. The hemorrhage 
was profuse and checked with great difficulty. If at hand, 
Horsley's wax would probably check the hemorrhage bet- 
ter than gauze. — Ed.] 

The treatment of a laceration of the urethra does not, 
as a rule, present any unusual difficulties. If, however, 
the bladder is lacerated at some inaccessible point, — as, 
for example, behind the symphysis,— the management of 
the case may become very difficult. The dribbling of the 
urine irritates the skin over the back of the pelvis and 
bed-sores develop which are very difficult to control. If 
possible, the patient should be placed in a permanent bath. 1 

2. HIP=JOINT 

Dislocation of the hip-joint is rather a rare injury, and 
requires severe violence for its production. The force acts 
indirectly through the trunk or the thigh, as when the in- 
jury is produced by a cave-in, by being run over, by a 
fall from a great height, etc. Dislocation by direct action on 
the region of the hip must be extremely rare. The most 
important forms are backward and forward dislocations, 
but they are very much more rare. Since the investiga- 
tions of Bigelow in Boston we know that the mechanism 
and the fixation of the luxated bone are determined by the 
iliofemoral ligament (or Bertini's ligament) [the Y-liga- 
ment. — Ed.], which in all regular dislocations remains in- 

1 See Mitchell's article (/. c.) for use of bath. 



FRACTURES OF THE LOWER EXTRE31ITY. 245 

tact. An irregular dislocation without characteristic symp- 
toms is possible only when that ligament has been torn. 

(A) Backward Dislocation (Luxatio postica sive 
retrocotyloidea). (Plates 50, 51, 52.) 

If the flexed and slightly abducted thigh is rotated in- 
ward, the posterior portion of the capsule is put on the 
stretch. If the movement is continued, the neck of the 
femur catches on the edge of the acetabulum and a fulcrum 
is provided so that by means of the long arm of the lever 
(the shaft of the femur) enormous power can be exerted 
on the short arm — the head of the femur. The head is 
forced against the capsule, which gives way at its posterior 
portion, and the head escapes from its articular connec- 
tions, the ligamentum teres being torn. Thus the back- 
ward dislocation is completed. 

AVe distinguish two forms : iliac and ischiatic disloca- 
tion. In the former the head is found on the iliac bone ; 
in the latter it occupies a deeper position on the upper seg- 
ment of the ischium. The position of the tendon of the 
obturator internus in relation to the head of the femur is 
an important anatomic distinction. In the iliac form the 
head of the femur is above, in the ischiatic form below, 
the tendon. An ischiatic dislocation may be produced 
experimentally by rotating the strongly flexed thigh in- 
ward. The iliac form is also produced by inward rota- 
tion, but w T ith the thigh in less pronounced flexion. 

In the living subject posterior dislocation is brought 
about in the same way, either by movement of the leg 
(rare), or, more frequently, by movement of the trunk or 
pelvis while the leg is fixed, the head of the femur 
becoming displaced above or below the tendon of the 
obturator muscle. Or the head may first escape from the 
acetabulum in its postero-inferior segment and, by secondary 
dislocation, approach the position characteristic of iliac 
dislocation, until the Y-shaped ligament and the external 



246 



FRACTURES AND DISLOCATIONS. 



PLATE 50. 

Backward Dislocation of the Thigh. — Fig. 1.— Ischiatic dislo- 
cation artificially produced in the cadaver. The gluteus maxiinus has 
been split, each part being held aside by retractors, so that the head of 
the femur and deeper-lying soft structures are exposed. Immediately 
below the gluteus maximus is a strip of tissue, belonging to the gluteus 
minimus, and under the latter, the pyriform muscle. The obturator 
internus occupies a position above the head of the femur, but lies at 
some depth, so that little is to be seen of it. Below the head, and sur- 
rounding it like a cravat, we see first the obturator externus, and lower 
down the quadratus femoris, some of the fibers of which are lacerated. 
On the median side of the head of the femur is the sciatic nerve; 
between it and the edge of the lower portion of the gluteus maximus 
are the tuberosity of the ischium and the tendon of the biceps femoris, 
which has its origin at that point. 

Fig. 2. — Anatomic preparation of the hip region seen from behind; 
the conditions are normal. The plate is explained by figure 119. 

Fig. 3. — Iliac dislocation, artificially produced in the anatomic 
specimen (see Fig. 2). The head of the femur is above the obturator 
internus. 



Piriformis 



Nerv. ischiadicus 



Glut. med. 



Glut. min. 




Fig. 119. 



Tab. JO. 




Fiy.£. 



Fig.3. 

Litk. Arist E Reichhoid. Miijichen . 



FRACTURES OF THE LOWER EXTREMITY. 247 

rotators, assuming that they are intact, arrest its progress. 
In such a case the head of the femur may be found behind 
the obturator interims ; i. e., the obturator and gemelli lie 
between the head and the acetabulum, and may constitute 
an obstacle to reduction. 

Symptoms. — In posterior dislocations the leg is rotated 
inward and fixed in more or less pronounced flexion and 
adduction. When the patient lies on his back, this 
deformity is readily recognized and is associated with 
shortening of the leg. It is greater in the iliac than in 
the ischiatic form. The shortening is demonstrable by 
actual mensuration. The legs are brought into symmetric 
position with respect to the pelvis, and the distances from 
the anterior superior spines to a point on the knee-joint — 
say, the lower edge of the patella or the median line of the 
knee — are measured. An easy method of estimating the 
shortening consists in flexing the two thighs at a right 
angle and placing them symmetrically with respect to the 
pelvis, and then comparing both sides. The pelvis must 
be absolutely horizontal ; that is, both anterior superior 
spines must be at the same level. In a posterior disloca- 
tion the knee of the injured side is considerably lower 
than the other, because the corresponding femur is dis- 
placed backward along the pelvis. This procedure is best 
carried out under anesthesia. 

The displacement of the parts in the hip region can also 
be accurately measured. Under normal conditions a line 
drawn from the anterior superior spine to the tuberosity 
of the ischium through the gluteal region crosses the tip 
of the trochanter major. This is known as the Roser-Nela- 
ton line. In posterior dislocation the end of the femur, 
and with it the trochanter, is pushed above this line. Its 
position above the line may be accurately determined by 
this method of examination, which requires that the patient 
lie on the sound side. The trochanter, and hence the head 
of the femur, providing it has not been separated from 
the neck and shaft of the bone, may thus be located. 



248 



FRACTURES AND DISLOCATIONS. 



By means of inward rotation additional information is 
obtained in this method of examination. When the con- 
ditions are normal and the thigh is midway between external 
and internal rotation, the tip of the trochanter corresponds 
approximately with the center of the Roser-Nelaton line. 
If the trochanter is found in front of this line, it indicates 
rotation, which is always present * in regular posterior 
dislocations, and shows that the head of the femur is pos- 
terior to the acetabulum. 

There is a simpler way of arriving at a rough estimate 
of the dislocation. With the pa- 
tient in the dorsal position and 
the limbs disposed symmetrically, 
the surgeon places his thumbs on 
the two anterior superior spines 
and determines the position of 
the tip of the trochanter with his 
index- fingers. The distance be- 
tween the two bony points may 
be estimated approximately by 
the number of fingers that can be 
crowded in between them, and the 
position of the tip of the tro- 
chanter with respect to the pelvis 
roughly determined. 

It is not always possible, owing 
to the overlying mass of the 
gluteal muscles, to demonstrate the head of the femur 
in its abnormal position, especially if there is much swell- 
ing, and the patient is not under anesthesia. 

Active movement is completely abolished. The thigh 
can be flexed passively, and the abnormal adduction and 
inward rotation can be increased to some extent, but not 

«.• Inhere is a back ward dislocation with external dislocation of the 
!i? lg w v 1S a rare in J UI X and possible only when the outer limb of 
the Y-shaped ligament is divided and the articular capsule extensively 




Fig. 120.— TheRoser-Ne- 
laton line with the thigh 
flexed at the hip. 



FRACTURES OF THE LOWER EXTREMITY. 249 

without giving intense pain. In attempting abduction and 
outward rotation of the thigh, a characteristic resilient re- 
sistance is encountered which is here due chiefly to the ten- 
sion of the Y-ligament. Freedom of passive movements, 
with great limitation of internal rotation of the dislocated 
thi^h, indicates a large rent in the capsule with laceration 
of the muscles. The characteristic resilient fixation is 
more distinct, the smaller the tear in the capsule and the 
less extensive the injury to the muscles. 




Fig. 121. — Reduction of a dislocated hip-joint with the patient in 
full anesthesia lying on the ground. The injured leg is placed at a 
right angle to the body. 

Treatment. — I have already remarked that anesthesia 
is practically indispensable in the examination. As soon as 
the diagnosis is established, the dislocation should be re- 
duced, and this procedure always demands anesthesia. The 
patient is laid flat on his back on a blanket or mattress 
on the ground. The injured leg is raised until the thigh 
forms a right angle with the body ; the surgeon then grasps 
the leg and flexes it at right angles at the knee. One assis- 



250 FRACTURES AND DISLOCATIONS. 

PLATES 51 and 52. 

Various Typical Forms of Dislocation of the Thigh in 
Preparations and in the Living Subject. — The corresponding 
conditions on the two plates bear the same numbers. In the anatomic 
specimens illustrated in Plate 51, the iliofemoral ligament is pre- 
served. 

Figs. 1 and 1 a. — Sciatic dislocation. 

Figs. 2 and 2 a. — Iliac dislocation. 

Figs. 3 and 3 a. — Obturator dislocation. 

Figs. 4 and 4 a. — Infrapubic dislocation. 



tant kneels on the ground and fixes the pelvis. In emer- 
gencies the surgeon may dispense with the assistant and fix 
the pelvis by bracing his foot against the symphysis, after 
removing his boot, taking care not to exert pressure on 
the urethra. In this position simple traction upward 
sometimes suffices to effect reduction, if the head lies near 
the posterior border of the acetabulum. If, however, the 
head is displaced further backward, simple traction on the 
leg will cause it to lodge on the edge of the acetabulum, 
and it is evident that abducting the thigh, which a priori 
seems a rational procedure, only serves to wedge the head 
more firmly in its abnormal position. Thus the advice to 
bring the thigh into adduction before exerting traction be- 
comes comprehensible, because this movement permits the 
head to glide more easily over the edge of the acetabulum. 
The manipulations, therefore, consist of traction in a posi- 
tion of adduction with some inward rotation. If this fails, 
the surgeon must try what traction in abduction with out- 
ward rotation will do. During this procedure the head of 
the femur sometimes slips around the outside of the edge 
of the acetabulum and becomes lodged in front of the 
articulation — so-called circumduction. The position of 
the head cannot therefore always be inferred from the na- 
ture of the laceration in the capsule, in view of the possi- 
bility of these secondary movements taking place. The 
capsular rent, which may be longitudinal or transverse, 



FRACTURES OF THE LOWER EXTREMITY. 251 

sometimes lias to be enlarged by appropriate movements. 
In some cases it forms a true obstacle to reduction, that 
cannot be removed without operative intervention. I 
have repeatedly reduced a dislocation of several weeks' 
standing in this way and obtained perfect mobility. In 
very old cases all hope of obtaining a movable joint must 
be abandoned and a resection or a subtrochanteric osteot- 
omy performed to correct the position of the limb. 



(B) Forward Dislocation (Luxatio antica sive prae- 
cotyloidea). (Plates 51 and 52.) 

The forward dislocation is rarer than the backward 
variety. After the detailed description which has been 
given of posterior dislocations, but little space need be 
devoted to it. 

An anterior dislocation may be produced artificially by 
outward rotation and abduction of the thigh. The capsule 
gives way in its anterior portion, somewhat above the 
middle, and if the thigh is at the same time overextended, 
a suprapubic dislocation results. If the tear in the cap- 
sule is lower down and the thigh is flexed, an infrapubic 
dislocation is produced. 

In the living subject forward dislocation is produced in 
the same way, or by a corresponding dislocation of the 
pelvis while the leg is fixed. 

In all forward dislocations the lower extremity is in a 
position of pronounced outward rotation and abduction. 1 
The degree of flexion varies ; in suprapubic dislocation it 
is slight, sometimes the limb is even in extension. In 
infrapubic dislocation flexion is always present, its degree 
depending on the extent to which the head of the femur 
is displaced inward; it is due to the tension of the 
Y-ligament. 

1 In very rare cases, when the head of the femur is displaced out- 
ward into the interior of the pelvis, inward rotation has been ob- 
served. 



252 FRACTURES AND DISLOCATIONS. 

In suprapubic dislocations the head is directly felt in the 
inguinal region ; it is found close to the edge of the 
acetabulum (iliopectineal dislocation with very little abduc- 
tion), or on the pubic bone (pubic dislocation), or below the 
anterior inferior spine (luxatio subspinosa, luxatio subpu- 
bica). The femoral artery is sometimes forced up from 
its bed by the head of the femur. Pain in the distribu- 
tion of the crural nerve is present. Sometimes the 
patient is still able to support himself on the injured leg. 

In the infra pubic variety there is outward rotation with 
marked abduction and flexion. We distinguish luxatio 
obturatoria when the head is found in the obturator fora- 
men ; and the very rare luxatio perinealis when the head 
occupies the ascending ramus of the ischium. In luxatio 
obturatoria the head is buried in the depths of the tissues 
and cannot easily be felt. The prominence of the tro- 
chanter is missed and the leg is fixed in its abnormal 
position to which it returns after removal of the reducing 
force. 

Diagnosis. — Fracture of the neck of the femur is ex- 
cluded by the fact that while in this injury the leg is also 
shortened and rotated outward, the characteristic elastic 
fixation found in dislocation-fracture is absent. The leg 
can be straightened without any difficulty, but at once 
returns to its position of outward rotation. Other move- 
ments are not impossible as in dislocation. 

Reduction. — In reducing a suprapubic dislocation it 
may be necessary to begin by overextending the thigh so 
as to bring the head of the bone nearer the acetabulum. 
The patient must be laid on a table. In all other forms 
the same rule holds good as for posterior dislocation; i. e., 
the patient must be fully anesthetized and laid on the floor, 
and reduction effected by manipulating the leg, which is 
flexed at the knee. Inward rotation followed by abduc- 
tion usually accomplishes the desired result. Circumduc- 
tion of the head around the edge of the acetabulum can be 
prevented by pulling on the thigh at the same time. 



FRACTURES OF THE LOWER EXTREMITY. 253 

(C) Rare Dislocations of the Hip- Joint 

Downward dislocation (luxatio infracotyloidea) is ex- 
tremely rare ; the head of the femur is found at the lower 
edge of the acetabulum, the leg is lengthened. Marked 
flexion is always present, and usually a slight degree of 
abduction. Rotation is of no importance. In several 
cases the patient was still able to stand and even to w T alk 
on the injured leg, the head of the bone being braced 
against the lower edge of the acetabulum. The disloca- 
tion may be produced by forced abduction. Reduction is 
effected by traction on the flexed thigh. 

Upward dislocation {luxatio supracotyloidea) is also 
very rare. The head is near the anterior inferior spine, 
where it is felt as a spherical prominence. The leg is ex- 
tended, rotated somewhat upward, and adducted ; at the 
same time it is considerably shortened. Reduction is 
effected by flexion and inward rotation. 

Among the irregular dislocations of the hip-joint (see 
page 245) should be included those in which the disloca- 
tion is complicated by fracture of the femur, be it the neck 
or the trochanteric region, or of the pelvis, whether of the 
edge of the acetabulum or the acetabulum itself. 

The term central dislocation {luxatio centralis) is used 
to designate an extremely rare accident in which the head 
of the bone is forced into the pelvis after the acetabulum 
has been demolished. The observation is of interest on 
account of its analogy to fracture of the base of the skull 
by the lower jaw. 

3. FEMUR 

(A) Fractures of the Upper End 

The upper end of the femur presents for examination 
the head, the neck, and the trochanteric region. The 
neck {collum femoris) lies between the cartilaginous border 
of the head and the trochanters ; or to be more precise, 
between the two ridges of bone connecting the two tro- 



254 



FRACTURES AND DISLOCATIONS. 



PLATE 52 a. 
Normal Hip= joint of a Lad Seventeen Years Old. 

graph. Anterior view. 



-Skia- 



Acetabulum 




Os ilium. 



Caput femoris 



Tuber isckiadicum 
Mamas sunerior ossis pubis 
/tomus inferior ossis fiubis 



• Trochanter mq/or 



Trocfuwter minor 



Femur 



chanters in front and behind ; that is to say, the neck lies 
between the intertrochanteric line in front and the inter- 
trochanteric crest behind, to follow the new anatomic 
nomenclature. The capsule, under normal conditions, 
surrounds not only the head of the femur, but also a con- 
siderable portion of the neck. It extends forward as far 
as the intertrochanteric line and backward to a point some- 
what beyond the middle of the distance between the head 
and the intertrochanteric crest. 

The upper end of the femur, in addition, includes the 



Tab. 52 a. 




FRACTURES OF THE LOWER EXTREMITY. 255 

trochanteric region and the upper portion of the shaft 
immediately below the trochanteric region. 

Fracture of the upper end of the femur may be pro- 
duced in a variety of ways. Except in severe perforating 
injuries, such as gunshot fractures, the head and neck are 
not exposed to direct violence. The trochanteric and in- 
fratrochanteric regions of the shaft may be broken directly 
by bending, torsion, or compression ; or indirectly by 
exaggerated movements at the hip-joint, such as adduc- 
tion, abduction, overextension, or rotation. The last possi- 
bility will be readily understood by any one who has tried 
to produce hip-joint dislocations on the cadaver. The 
forcible movements of the thigh against the flexed pelvis 
often lead to fracture of the upper end of the femur before 
dislocation is produced. In the mechanism of these frac- 
tures the iliofemoral ligament, or ligament of Bertini, plays 
a conspicuous role, as do the attachments of the capsule 
and muscles. [According to Allis, of Philadelphia, 1 frac- 
tures of the pelvis rather than the femur quite frequently 
take place from an indirect violence exerted through the 
long axis of the femur. He has observed this clinically 
and experimentally. — Ed.] 

Anatomically we distinguish the following forms : 

1. Intracapsular fracture of the neck of the femur; the 
line of fracture corresponds to the junction between the 
head and the neck. 

2. Traumatic epiphyseal separation at the upper end of 
the femur. 

3. Extracapsular fracture of the neck of the femur ; the 
line of fracture crosses the trochanter near the neck of the 
femur. 

4. Fracture of the femur in the trochanteric region. 

5. Isolated fracture of the trochanter major. 

6. Fracture of the femur in the upper portion of the 
shaft, immediately below the trochanters. 

1 Transactions of the American Surgical Association, vol. xix, 1901, 
p. 145. 



256 FRACTURES AND DISLOCATIONS. 

PLATE 53. 

Intracapsular (Median) Fracture of the Neck of the Femur 
(Fractura Colli Femoris Medialis).— Figs. 1 a and 1 b — Pseudar- 
throsis at the seat of the intracapsular fracture ; the neck of the femur 
has gradually disappeared by attrition. The head is fixed within the 
acetabulum by massive, newly formed adhesions. The trochanteric 
region presents a true nearthrosis within the old articular capsule, and 
articulates with the broken surface of the head. Both broken surfaces 
are smooth and almost polished in places, just as in arthritis deform- 
ans. Characteristic bony deposits are found both on the edge of the 
acetabulum and on the upper end of the femur. The latter is thick- 
ened and club-shaped by the enormous new-formation of bone. The 
false joint has permitted the two broken surfaces to glide up and down, 
and even shows the traces of this movement, as is indicated in the 
figure. (Author's collection. ) 

Figs. 2 a and 2 b. — Impacted intracapsular fracture. The specimen 
was taken from a woman eighty-two years of age (Glowe). Figure 2 a 
shows the upper end of the femur seen from the side, with the probable 
normal outline. The abnormally high position of the trochanter major 
caused by the fracture is shown. The neck of the femur has been 
shortened by the impaction. Figure 2 b presents a frontal section of 
the bone. The impaction has been broken up and the head is shown 
in the position which it was made to occupy by the impaction. The 
shaft is in adduction with respect to the head of the femur or pelvis. 
(Author's collection.) 

In practice we distinguish the following : 
(a) Fractures of the Neck of the Femur (Fractura 
colli femoris). — These are relatively frequent. The division 
into intracapsular and extracapsular, while correct in the- 
ory, must be qualified in practice. The lines of fracture 
are not always transverse, and the relations of the capsule 
are neither uniform nor of any vital importance. In so- 
called extracapsular fractures the line of fracture often 
enters the capsule, if only because, as has been stated, the 
anterior portion of the capsule extends as far as the inter- 
trochanteric line ; hence the extracapsular fractures of the 
books are usually mixed — i. e. } they are partly intracapsu- 
lar and partly extracapsular. 



Tab.53. 




Fuj.l b 




Fig.Zb 




Fig. 2 a 

LiXh.Anst F. Reidihold. Man die n . 



FRACTURES OF THE LOWER EXTREMITY. 257 

To preserve the anatomic names, we might divide frac- 
tures of the neck of the femur into median or proximal, 
and lateral or distal, fractures. 

Median fractures of the neck of the femur occupy the 
median segment of the neck of the femur, near the margin 
of the head, and are almost always intracapsular. The 
fragments consist of the shaft and neck, on the one hand, 
and the head, on the other. The head loses that part of 
its arterial blood-supply which is conveyed by the perios- 
teum and by way of the neck. The circulation through 
the ligamentum teres, in old persons especially, is poor. 
The head may be cut off from all nutrition, like a com- 
pletely separated fragment, and may succumb to retrogres- 
sive changes analogous to those that occur in the formation 
of a traumatic "joint-mouse." 

The lateral fractures occupy the lateral portion of the 
neck of the femur near the trochanters. They may be 
extracapsular, but as a rule they are mixed ; i. e., the line 
of fracture is partly within and partly without the capsule. 
The upper fragment consists of the head and part of the 
neck, and is abundantly supplied with arterial blood 
through the capsule and periosteum. 

There is much to be said in favor of this classification ; 
as w T e go on, we shall learn of still other advantages that 
it possesses. 

Etiology. — The ordinary fractures of the neck of the 
femur, as already remarked, are as a rule due to direct 
violence. The injuries which tend to produce them are of 
two kinds : 

1. A fall on the knee, or, more rarely, on the foot with 
the leg extended, so that the blow is transmitted in the 
direction of the shaft and comes on the neck. As the head 
is fixed within the acetabulum, a fracture of the neck 
results if this force is sufficiently severe. In most cases 
the fracture is median. This is therefore a kind of com- 
pression-fracture. 

2. A fait on the trochanter major — i. e., on the side of 

17 



258 FRACTURES AND DISLOCATIONS. 

PLATE 54. 

Extracapsular or Lateral Fractures of the Neck of the Femur 
(Fractura Colli Femoris Lateralis).— Figs. 1 a and 1 b.~ Extra- 
capsular fracture of the neck of the femur with impaction ; compara- 
tively recent ; from an old woman. The fracture is distinctly extra- 
capsular and even involves the trochanter. Figure 1 a shows the outer 
and upper surface ; figure 1 b a frontal section of the specimen. The 
impaction is very distinct ; the cervical fragment is driven into the 
trochanteric region. The neck is therefore shortened and forms almost 
a right angle with the shaft of the femur. In figure 1 b the outline of 
the corresponding sound limb is indicated, showing the total shorten- 
ing of the injured thigh and the relatively higher position of the tro- 
chanter. (Author's collection.) 

Figs. 2 a and 2 b.— Old extracapsular fracture of the neck of the 
femur with impaction ; bony union. The specimen was taken from a 
woman eighty-two years old (Glowe) who had sustained an intracap- 
sular fracture on the other leg (see Plate 53, Fig. 2). The fracture 
illustrated in the picture was produced in November, 1888. After the 
patient's death in March, 1893, the specimen illustrated in the plate 
was obtained at the autopsy. (Author's collection. ) 



the body. The body striking against the ground, stone 
pavement, or wooden floor brings about a compression of 
the neck of the femur in its longitudinal axis, between the 
head and the trochanteric region. This compression, as in 
the analogous case of force applied to the long bones 
(upper end of the humerus), produces a fracture at the 
point of junction between the thinner compact neck of the 
femur and the more voluminous and spongy tissue of the 
adjacent region. Fracture takes place either at the junc- 
tion of head and neck, or at the junction between the neck 
and the trochanteric region ; in other words, either a 
median or, what is more usual, a lateral fracture of the 
neck of the femur is produced. These fractures, like 
other compression-fractures, are usually characterized by 
impaction of the fragments. 

In lateral fractures of the neck of the femur the lines 
of fracture extend into the trochanteric region ; inversely, 



Tab. 5 4. 




Fuji b 





Fig.Si 










Eig.Zb 

Lith. Anst.E Reichhold, Munch en . 



FRACTURES OF THE LOWER EXTREMITY. 259 

forced rotation by means of the ligaments, especially the 
Y-ligament, may bring about fractures in the upper por- 
tion of the trochanteric region, the line of fracture extend- 
ing into the adjacent portion of the neck of the femur. In 
practice these fractures can probably not be distinguished 
from fractures of the neck, and are therefore to be included 
among the lateral fractures. 

The great incidence of these fractures in old persons is 
explained by the greater brittleness of the bones, which is 
most pronounced at the upper end of the femur. We 
know that under normal conditions this structure is very 
firm and quite adequate to the task of supporting the body. 
The significance of the architecture of the bone trabecular 
is well known ; they satisfy the highest mathematical and 
mechanical demands, and with the least amount of mate- 
rial in the form of bone-substance combine the highest 
possible strength. In old age the bone trabecular become 
less numerous and the fat-containing cavities between 
them increase in size, Avhile the bone itself suffers a loss 
of organic substance. This leads to the production of an 
osteoporosis, which makes its appearance earlier in women 
than in men, and thus explains the greater frequency of 
fracture of the neck in women. Another factor is the 
angle which the neck of the femur forms with the shaft. 
This angle is subject to variations. The more it ap- 
proaches a right angle, the more easily a force acting from 
below in the direction of the shaft of the femur will cause 
a fracture. As this angle is said to diminish as age ad- 
vances, we have another explanation for the greater fre- 
quency of the accident in old people ; but it is a great 
mistake to imagine that many older persons are liable to 
fractures of the neck of the femur. The accident is also 
observed in vigorous middle-aged mien and even in youth- 
ful individuals, although, it must be admitted, with much 
less frequency. 

Morbid Anatomy. — The study of Plates 53, 54, and 
55, and the accompanying descriptions, coupled with the 



260 FRACTURES AND DISLOCATIONS. 

PLATE 55. 

Outward Rotation of the Thigh in Intracapsular (Median) 
Fracture of the Neck of the Femur. — Fig. 1.— Anterior view of 
the upper extremity of the left femur. 

Fig. 2. — Posterior view of the same specimen. 

Fig. 3. — Horizontal section through the neck and head of the same 
specimen. The section is somewhat oblique and follows the direction 
of the neck, upward toward the head. 

Fig. 4. — In the same horizontal section of this specimen the cross- 
section of the corresponding normal neck of the femur is indicated in 
outline. The high grade of rotatory displacement of the fragments is 
well seen. 

Fig. 5. — Frontal section through the normal upper end of the femur 
and acetabulum, from a child eight years old. The epiphyseal line is 
made out between the head and neck of the femur. The epiphysis is 
formed solely by the head of the femur. The greater trochanter has 
its own ' l anlage ' ' (apophysis) . 

succeeding remarks, will suffice to show how typical the 
appearances are in this fracture. 

Median fractures of the neck of the femur are rare ; 
they may be either loose or impacted ; the impaction is 
probably never permanent. Bony union is a rare excep- 
tion ; although the anatomic specimens (Plate 55) show 
that it is a possibility. As a rule, a false joint is formed 
by the movements of the leg when the patient begins to use 
it. The pseudarthrosis represents a kind of sliding joint, 
due to the upward and downward movement of the end 
of the bone. In the most typical form the neck of the 
femur is lost through attrition, and the smooth surface of 
the trochanteric region articulates with the equally smooth 
fractured surface of the head. The head itself, as a rule, 
becomes fixed within the acetabulum by fibrous or bony 
adhesions. 

Lateral fractures of the neck of the femur are much 
more common ; in some cases they are impacted. Bony 
union is the rule, even when the case is not treated by 
a surgeon. An abundant callus-formation usually takes 



Tab. 5*. 




Tig A. 



A 





\ 



w 

Fig 2. 




Fig. * 




Fig.,3. 




Fig. A. 

Ltih, Anst.E Reich ho Id. Munchcii . 



FRACTURES OF THE LOWER EXTREMITY. 261 

place at the outer portion of the neck, and especially in 
the entire trochanteric region. The impaction may be- 
come loosened, especially if the patient uses his leg too 
earlv without any protective apparatus. A slight de- 
formity may in this way become very much increased. 

In fractures of the neck of the femur there is nearly 
alwavs, in addition to the vertical displacement, some de- 
gree of outward rotation of the shaft, even when the frac- 
ture is impacted. In some cases this is a very prominent 
symptom. The outward rotation of the thigh is usually 
interpreted as the result of gravity causing the limb to fall 
outward. More recently a theory which appears to me 
more plausible has been advanced — namely, that the pos- 
terior portion of the neck of the femur being weaker, a 
force applied to the trochanter from without causes a more 
extensive fracture of the posterior periphery of the neck 
of the femur than in the remaining parts of the structure 
(Kocher). 

What has been said applies equally to incomplete frac- 
tures or infractions of the neck of the femur. These may 
occur in the lateral, as w r ell as in the median region, and 
may present only an angular depression of one side of the 
neck, in its upper, or preferably posterior, portion, usually 
associated with partial impaction. A considerable vari- 
ation may thus be brought about in the angle formed by 
the neck of the femur with the shaft. 

Symptoms. — If an elderly person is unable to stand 
after a fall on the knee or on the side of the body, and the 
injured limb exhibits the phenomena of shortening and out- 
ward rotation, the surgeon should always think of frac- 
ture of the neck of the femur. The condition must be 
differentiated from distortions, contusions, dislocations of 
the hip-joint, and fracture of the pelvis. It is hardly con- 
ceivable that the injury should be mistaken for dislocation, 
since outward rotation occurs only in anterior dislocation 
of the hip-joint. When the patient is lying in bed, he is 
unable to raise the injured limb or, in other words, to per- 



262 FRACTURES AND DISLOCATIONS. 

form active flexion at the hip-joint. The leg usually lies 
in full extension without adduction or abduction. 

Direct palpation of the seat of fracture is possible only 
when the trochanter has been involved, and then only to 
a very limited extent. While it is true that under normal 
conditions the greater trochanter can be felt in front, on the 
outside, and behind, it must be remembered that the struc- 
ture is much less accessible after an injury to this region ; 
hence it is rarely possible to make out the sharp edge of a 
fracture on the greater trochanter. 

An important symptom is the apparent upward displace- 
ment of the trochanter, the position of which is determined 
in the same way as in the backward dislocation of the hip- 
joint. AVhen the limbs are placed symmetrically with re- 
spect to the pelvis, it is found by mensuration that the 
distance from the anterior superior spine to the knee is 
considerably shorter than on the sound side. If it is 
found that the tip of the trochanter projects beyond the 
Roser-Xelaton line a distance equal to this shortening, it is 
a sign that the rest of the femur is intact, and the cause of 
the shortening is to be sought either in the neck of the 
femur or in the hip-joint. This result is controlled by 
finding that the distance from the tip of the trochanter to 
the knee, measured between the corresponding points, is 
the same on both sides. The shortening in such a case is 
due to displacement of the fragments occurring at the time 
of the injury and to the traction of the muscles acting ou 
the shaft of the femur and trochanter (see Plates 53 and 
54). 

As a consequence of the shortening of the neck the tro- 
chanteric region is nearer the median line of the body in 
fractures of the neck of the femur, but the method of 
measuring the difference on the two sides is so difficult and 
inexact that it is of no practical value. 

[In mensuration for diagnosis of fractures of the femur 
most authorities prefer to measure between the anterior 
iliac spine and external or internal malleolus. The mal- 



FRACTURES OF THE LOWER EXTREMITY. 263 

leolus seems to be a more fixed bony prominence than the 
patella. In fractures at the upper end of the femur or 
dislocations we have in English a certain terminology in 
regard to shortening and lengthening. When the patient 
is in the dorsal position, with the lower limbs parallel and 
the anterior iliac spine in the same horizontal plane, the 
limbs should be, in a normal individual, of the same 
apparent length. If the extremity under examination is 
shorter or longer, we speak of apparent lengthening or 
apparent shortening. When Ave measure between the ante- 
rior iliac spine and the malleolus, Ave speak of a measured 
lengthening or a measured shortening. If we find a measured 
difference between the anterior iliac spine and the tro- 
chanter, or the trochanter and the external malleolus, Ave 
speak of a reed shortening. These are the most important 
measurements. The apparent difference or the measured 
difference between the anterior iliac spine and the malleolus 
does not of itself indicate that there is any real difference 
in the length of the limb, because an adducted limb looks 
shorter, but measures more between the anterior iliac spine 
and the external malleolus, so that in the normal limb 
adduction giA 7 es apparent shortening and measured length- 
ening, but no real shortening. The reverse is true of 
abduction. This should be borne in mind in the mensura- 
tion, because it is not ahvays possible to fix the anterior 
iliac spine on the same horizontal plane and have the lower 
limbs in the same relation to the pelvis. If an adducted 
leg measures the same or less than the other limb, there 
must be some real shortening, and this measurement is of 
the greatest importance Avhen, on account of sAvelling pal- 
pation of the trochanter is difficult or impossible. In 
fractures of the upper end of the femur, especially of the 
neck, the diagnosis can be made by measurements only. 
Manipulations to elicit crepitus are unnecessary, and would 
break up impaction if present. — Ed.] 

The injured limb can be moved in all directions, but 
not Avithout giving pain. Crepitus is present unless the 



264 FRACTURES AND DISLOCATIONS. 

displacement has been so great that the fragments are no 
longer in contact. When the leg is extended and rotated 
about its longitudinal axis, a phenomenon is developed 
which is readily explained : In a median fracture the shaft 
of the femur revolves about an axis, the length of which 
corresponds to the fragment of the neck that is preserved 
intact and still remains attached to the femur. In a lateral 
fracture, on the other hand, the shaft of the femur turns 
only about its longitudinal axis, providing of course there 
is no impaction. 




Fig. 122. — Displacement of the trochanter in fracture of the neck 
of the femur. Posterior view, on the right side. The illustration 
shows the upward displacement of the trochanter toward the anterior 
superior spine, which is indicated by a horizontal line. The left side 
shows the normal relations. 

Impacted fractures of the neck of the femur, as a rule, 
present no diagnostic difficulties ; they are always charac- 
terized by shortening and outward rotation of the leg, 
though both these symptoms are less pronounced than in 
fractures without impaction ; in addition, there is some- 
times a slight degree of adduction. These phenomena are 
all directly due to the displacement and subsequent impac- 
tion of the fragments. Crepitus is absent in impacted 



FRACTURES OF THE LOWER EXTREMITY. 265 

fractures, but considerable movement is often possible at 
the hip-joint. Rotation of the leg about its long axis at 
the hip-joint takes place about a radius corresponding to 
the length of the neck of the femur. 

The clinical history that is obtained when an impacted 
fracture of the femur has been neglected or improperly 
treated, and the impaction later becomes broken up, is quite 
characteristic. The following case recently came under 
my observation : A woman (Lange), seventy-four years of 
age, on the 17th of May, 1896, fell from a step and 
struck her hip on the floor of the room. She was able to 
support her weight and move about, although not without 
great pain. In the beginning of August the pain suddenly 
became more severe, having been brought on, according to 
the patient, by sitting down on the edge of the bed. The 
patient now took to her bed and was treated with an exten- 
sion apparatus. In this case the patient had walked about 
with an impacted fracture of the neck of the femur for a 
period of about two and a half months, after which the 
condition suddenly took a turn for the worse and the im- 
pacted fragments became loosened. 

Incomplete fracture of the neck of the femur (infractions) 
cannot be positively differentiated from impacted fractures. 
The same upward displacement of the trochanter with a 
certain degree of outward rotation is present, owing to the 
fact that the posterior wall of the neck is thinner and sus- 
tains a deeper infraction. This class includes the cases of 
so-called coxa vara of traumatic origin. 

[Incomplete fractures of the neck of the femur are not 
infrequently overlooked, especially in children, and not 
uncommonly in adults. The injury may be slight, the 
patients either do not go to bed at all, or stay there but a 
short time. The deformity due to the bending upward and 
backward of the neck of the femur at the seat of fracture 
may develop very slowly, and it is frequently some months 
before the complete picture and functional disability of 
traumatic coxa vara is established. Without much doubt, 



266 FRACTURES AND DISLOCATIONS. 

most of these cases could have been recognized in their 
recent state by careful measurements or an X-ray photo- 
graph. Sprengel l was the first to call attention to this. 
The recent literature is quite full of observations confirm- 
ing Sprengel (see Progressive Medicine for December, 
1899 and 1900.— Ed.] 

Treatment. — As the accident usually happens to old 
people, the general treatment and the maintenance or im- 
provement of the patient's strength are of prime impor- 
tance. If a hypostatic pneumonia makes its appearance, 
the case is practically hopeless, and the patient should 
therefore be encouraged to sit up and take deep breaths 
from time to time. Nutritious food must be supplied and 
the position of the body changed as often as possible. 
These are the cases in which the patient should be gotten 
up out of bed and made to walk about with an ambulatory 
splint as early as possible. 

Lateral fracture usually heals by bony union. In gen- 
eral, the proliferation of bone in fractures or after osteot- 
omy in the trochanteric region is very abundant. Median 
fractures, on the other hand, rarely unite by the formation 
of callus, because of the interference with the nutrition of 
the head, which is connected to its surroundings only by 
the ligamentum teres ; this has been referred to. In many 
cases a true pseudarthrosis results ; the head, which be- 
comes fixed within the acetabulum, and the cervical frag- 
ment by constant attrition are gradually rubbed smooth 
and the two surfaces form a perfect sliding-joint. 

If the diagnosis of impaction or incomplete fracture has 
been made, the limb must be placed at rest and protected 
against all injuries until sufficiently firm union for func- 
tional use has been obtained. For weeks after the injury 
there is danger of the impaction breaking up and the 
fragments becoming displaced, an event which is anything 
but desirable. The greatest care is therefore necessary in 
such cases. Nevertheless the patient must get up and 
1 Arch. f. klin. Chir., 1898. Bd. lvii. 



FRACTURES OF THE LOWER EXTREMITY. 267 

walk about with an ambulatory splint at an early stage of 
the treatment. 

In ordinary cases of fracture of the neck the fragments 
should be replaced as accurately as circumstances will 
permit by extension and inward rotation. A permanent 
extension dressing is then applied according to the prin- 
ciples of bandaging. The foot is to be supported on a well- 
padded sliding foot-rest (Volkmann's sled) ; outward ro- 
tation of the leg must be prevented. From 12 to 15 
pounds suffice in most cases to bring the fragments into a 
favorable position. The dressing should be applied in 
such a way as to allow the patient considerable freedom of 
movement as he lies in bed. He may lie on his side or 
even be propped up with pillows without sustaining any 
injury or suffering pain. No additional splint is neces- 
sary. A plaster cast or an ordinary splint dressing may 
of course be used if desired. The recently invented am- 
bulatory splints of Thomas, Liermann, Bruns, and others 
are particularly useful for this class of cases. In these 
splints the tuberosity of the ischium forms the fixed point 
and allows the application of permanent extension by 
means of a rubber band which may be replaced during 
the night by an ordinary apparatus with pulley and 
weights. 

Operative fixation of the fragments by the insertion of 
a gimlet or nails from without is indicated only in very 
special cases. Recently Kocher has advised early resec- 
tion of the head as the best method of treating a simple 
intracapsular (median) fracture of the neck. If this pro- 
cedure is contraindicated by extreme age or weakness on 
the part of the patient, massage and passive movements 
should be begun as early as possible. The ultimate result 
in most cases is not very brilliant. In the case of old and 
infirm persons the surgeon may be glad if they eventually 
are able to walk at all with the aid of a cane. In more 
vigorous subjects the results are much more satisfactory ; 
and if the treatment has been successful, may be very fav- 



268 FRACTURES AND DISLOCATIONS. 

orable, both as regards absence of deformity and the res- 
toration of function (compare statistics on page 60). 

[I have had three excellent results after resection of 
the head of the femur in cases of traumatic coxa vara with 
marked deformity and functional disability. After re- 
moving all or a part of the head, the rounded neck has 
been placed in the acetabular cavity. I have covered the 
surface of the acetabulum and the rounded end of the neck 
of the femur with wax, hoping to prevent bony union. 
Apparently it has been successful, as these patients have 
moderate motion at the hip-joint. Many cases of old 
fracture of the neck of the femur with marked functional 
disability would be greatly improved by resection of the 
head. — Ed.] 

(b) Traumatic Epiphyseal Separation at the Upper 
End of the Femur (See Plate 55, Fig. 5).— -This is a 
rare injury, and of course occurs only in youthful individ- 
uals. In this respect, therefore, there is a great difference 
between the femur and the humerus, for at the upper end 
of the humerus epiphyseal separations are relatively fre- 
quent. The explanation is found in the small size and 
hidden position of the epiphysis at the upper end of the 
femur, and more particularly in the fact that it is strictly 
intra-articular; that is to say, not even a piece of the cap- 
sule, not to mention a ligament, is attached to the epiphy- 
sis. The mode of production and symptoms are the same 
as for median fracture of the neck of the femur. The 
treatment also is analogous to the treatment of that injury. 

Recent investigations of the anatomic conditions in trau- 
matic epiphyseal separation have shown it to be the cause 
of the clinical picture known under the name of coxa vara 
(Sprengel 1 ). 

[This injury in its recent state is frequently overlooked, 

because at first in many cases the deformity and symptoms 

are slight, the patients usually walking about, sometimes 

at first without a limp. For this reason they come to the 

1 Arch. f. klin. Chir., vol. lvii. 



FRACTURES OF THE LOWER EXTREMITY. 



269 



surgeon first, a number of weeks or months after the in- 
jury, when the symptoms of the deformity of coxa vara 
traumatica are fully developed. In a few cases observed 
in the recent state the dislocation of the upper fragment 
has been so marked that complete reduction has been im- 
possible. An immediate operation in such instances 
would undoubtedly be the best procedure. — Ed.] 

(c) Fracture of the Femur in 
the Trochanteric Region. — Frac- 
tures extending into the trochanteric 
region usually form part of a lateral 
fracture of the neck or, as will be 
seen presently, of infratrochanteric 
fracture of the femur. The symp- 
toms and treatment call for no special 
remarks. 

Isolated fracture of the greater 
trochanter is significant both from a 
practical and from a theoretic stand- 
point. It is a very rare injury, 
produced by direct violence, and logi- 
cally characterized by longitudinal 
displacement with separation of the 
bony process {ad longitudinem cum 
distractione). The fragment is dis- 
placed upward and backward by the 
action of the gluteal muscles and is 
directly accessible to palpation ; be- 
tween it and the femur is a wide 
diastasis. 

The simplest treatment consists 
in nailing on the fragment after replacing it as accurately 
as possible. This is facilitated by bringing the leg into 
abduction. 

(d) Fracture of the Shaft of the Femur below 
the Trochanter {Fraetura femoris mfratrochanterica). 
(Plate 56.) — Fracture of the shaft of the femur presents. 




Fig. 123.— The same 
specimen as shown in 
figure 1 of Plate 56, 
seen from without. The 
upper fragment is in a 
position of flexion ; the 
shaft is displaced for- 
ward and upward. 



270 FRACTURES AND DISLOCATIONS. 

PLATE 56. 

Various Fractures of the Femur. — Fig. 1. — Oblique fracture 
of the left femur below the trochanter ; posterior view (fractura femo- 
ris infratrochanterica) . United by robust masses of callus, with dis- 
placement of the fragments. The fracture was probably produced by 
overextension. (Pathol. Inst., Greifswald.) 

Fig. 2. — Oblique fracture of the upper half of the femur. Tor- 
sion-fracture with displacement of the fragment. The line of fracture 
involves the greater trochanter. (Pathol. Inst., Miinchen.) 

Fig. 3. — Oblique fracture of the lower half of the femur with 
lateral displacement and shortening ; union by moderate development 
of callus. (Author's collection.) 

Fig. 4. — Transverse fracture of the lower half of the femur with 
marked displacement ; united by abundant callus-formation. The 
displacement of the fragments corresponds to that which is typical of 
supracondylar fractures (see Plate 58). (Pathol. Instit., Greifswald.) 

no less peculiarities than the same injury at the lower end, 
above the condyles (fractura supracondylica). 

Mode of Production. — It occurs by bending or longi- 
tudinal compression, the result of direct violence, such as 
a blow, or a fall on uneven ground, bringing the part into 
contact with the ground, in which case a transverse frac- 
ture is produced ; or, as the result of indirect violence by 
toi*sion, as in falling on the feet, or in twisting of the body 
(cave-ins, etc.), in which case it takes the form of a spiral 
fracture with an oblique or almost longitudinal line of 
fracture. Examples of the latter variety are found in 
relatively large numbers in pathologic collections. 

This fracture is occasionally met with in adults who do 
heavy work which exposes them to accidents ; advanced 
age exhibits no special predisposition. 

Symptoms. — In addition to the general symptoms of 
fracture, which are usually present in full array, the clin- 
ical picture is characterized chiefly by the tendency of the 
upper fragment to assume a position of marked flexion, 
sometimes amounting to a right angle, under the influence 
of the iliopsoas and gluteal muscles. On examining the 



Tab. 56. 





Fiff.3. 




Fiff.4- 



LUK.Anst E Reichlwltl . Miinrlicn. 



FRACTURES OF THE LOWER EXTREMITY. 271 

injured limb, abnormal mobility, etc., are found below the 
trochanter. In moving the limb, especially rotating the 
thigh, it is noticed that the trochanter does not accompany 
the shaft. If the fracture is seen for the first time 
several weeks after the injury, typical displacement of the 
fragments, with abundant callus-formation, is usually dis- 
covered. 

Treatment. — Eeplacement of the fragments in as nearly 
a perfect position as possible, if necessary under anesthesia. 
Permanent extension dressing with heavy weights, the 
thigh being flexed to a greater or less degree on the abdo- 
men. For the rest, the treatment should follow the general 
principles that apply to the management of non-impacted 
fractures of the neck and shaft of the femur. 

[In fractures just below the trochanter I have found a 
combination of extension with fixation of the thigh, hip, 
and pelvis in plaster a very satisfactory method. Exten- 
sion is first applied to a position about the middle third of 
the thigh ; the patient is then anesthetized ; strong traction 
is made on the limb in a flexed and abducted position ; 
the thigh and pelvis are fixed in plaster. If properly 
applied, this is a very comfortable dressing. The results 
have been excellent. — Ed.] 

(B) Fractures of the Shaft of the Femur. (Plates 

56, 57, 58.) 

For fractures of the upper, diaphyseal segment see pre- 
ceding section (page 269). 

Fractures in the central portion of the shaft, especially 
somew r hat above the center, are common. Some of these 
fractures are produced by torsion, and assume the form of 
oblique or longitudinal fractures ; but the majority are 
caused by bending due to direct violence, as, for instance, in 
being run over. 

These fractures frequently occur in children, and are 
relatively favorable from the fact that the fracture is apt to 



272 FRACTURES AND DISLOCATIONS. 

PLATE 57. 
Typical Deformity in Fracture of the Middle of the Femur. 

— Fig. 1. — Muscle-preparation to explain the flexion of the upper frag- 
ment in fracture of the femur. The figure shows the iliopsoas 
muscle attached to the lesser trochanter. In this position of the speci- 
men the picture, which was taken accurately from nature, can only 
show the gluteus medius, because it is the only one of the gluteal mus- 
cles that extends far enough forward on the pelvis to become visible. 

Fig. 2. — Fracture of the right femur about its middle, in a boy 
twelve years of age (Hermann Binder, 1893) ; united with deformity. 
The picture shows shortening of the right femur; depression of the 
right half of the pelvis; and the right groin more nearly horizontal 
than the left. The thigh presents, immediately above the middle of 
the shaft, an angular prominence extending forward and outward. 

Fig. 2 a. — Condition at the time of discharge from clinical treat- 
ment a few weeks later. The thigh had been broken at the seat of the 
fracture by osteoclasis and the deformity corrected by means of adhe- 
sive-plaster bandage and extension with heavy weights, with the thigh 
in abduction and moderate flexion. Its recurrence was prevented 
during the second period of treatment. The thigh is straight, and 
more nearly approaches its fellow in length. 



be transverse, with preservation of the iliac periosteum, 
thus preventing any considerable displacement of the frag- 
ments. In adults, on the other hand, there is usually 
marked displacement of the fragments ; the line of frac- 
ture is usually oblique and favors the production of defor- 
mity by the traction of the enormous mass of muscles, the 
effect of which is exerted chiefly in the longitudinal direc- 
tion. As a rule, it is easy to demonstrate abnormal 
mobility. Crepitation ought to be well marked, and I 
must insist on the importance of establishing the presence 
or absence of this symptom beyond a doubt ; for if crepi- 
tation is absent, either great overriding of the fragment or 
interposition of soft parts is to be assumed. Crepitation 
is established in order to bring the surfaces into the desired 
contact and guarantee union in good position. The short- 
ening brought about by longitudinal displacement of the 




Ihb 57. 





Lith.Anst /'.' Reulihold ', MuncJicn. 



FRACTURES OF THE LOWER EXTREMITY. 



273 



fragments is always easy to determine by measuring the 
distance from the knee, — i. e., the lower edge of the patella 
to the trochanter, or, better, to the anterior superior spine, 
— when the legs are in perfectly symmetric position. 

Fractures above the middle of the shaft are character- 
ized by a typical deformity 
which, I regret to say, is 
only too often noticed after 
the fracture has united when 
the patient again seeks medi- 
cal or surgical aid for the 
angular deformity. Frac- 
ture of the shaft of the 
femur that has united with 
deformity shows, above the 
middle of the shaft, at the 
seat of fracture, an angular 
prominence directed out- 
ward and forward. In other 
words, the upper fragment 
is flexed by the action 
of the iliopsoas muscle at- 
tached to the greater and 
minor trochanters, and ab- 
ducted by the glutei. The 
lower fragment overrides 
the upper at the seat of frac- 
ture, while the lower por- 
tion of the shaft is still 
under the influence of the 
adductor muscles. In this 
way the above-mentioned 
angular deformity is produced. More rarely an incur- 
vated deformity results at the seat of fracture (see Fig. 
124) ; these deformities can easily be avoided by appro- 
priate treatment. 

In cases with much deformity, especially if some of the 
18 





Fig. 124.— Fracture in the 
middle of the femur in a man 
thirty years of age, united in bad 
(incurvated) position, with sketch 
of a femur to explain the de- 
formity. 



274 



FRACTURES AND DISLOCATIONS. 



soft parts have been interposed between the fragments, a 
pseudarthrosis quite commonly develops (Fig. 125). 

Treatment. — The treatment 
of fractures of the shaft of the 
femur has become much sim- 
plified since the adoption of 
permanent extension by means 
of weights. This method neu- 
tralizes the effect of die muscle 
and enables us to avoid secon- 
dary displacement ; but it is a 
mistake to suppose that the 
treatment is anything but a 
laborious one. In the first 
place, the dressing must be ac- 
curately applied so that there 
will be no pressure at any 
spot ; it must be wide enough 
and strong enough to permit 
the application of 20 to 25 
pounds. Adhesive strips made 
of strong sailcloth or Heusner's 
strips (see page 71) are used. 
To prevent friction of the leg 
against the mattress a sliding 
foot-rest (Volkmann's sled) is 
used which at the same time 
allows the foot to be placed in 
a certain position, if necessary 
in rotation. Counterex tension 
is best effected by raising the 
foot of the bed on blocks of 
wood or bricks, and laying 
another block under the sound 
foot so as to give it something 
to brace against (Fig. 127). As an aid to the treat- 
ment by extension, even when used in fractures of the 




Fig. 125. — Pseudarthrosis of 
the femur after fracture some- 
what below the middle. In 
this position the prominence 
of the upper fragment is seen 
above the knee-joint. Extra- 
ordinary longitudinal displace- 
ment. Operation : Kesection 
of the ends of the bones and 
lengthening of the femur. 
Firm union. 



FRACTURES OF THE LOWER EXTREMITY. 



275 



upper extremity, I would recommend a procedure which I 
have employed for many years, and which consists in 






Fig. 126. — Simple "sled" or sliding foot-rest, consisting of three 
pieces which are easily fitted together and can, if necessary, be readily 
improvised. 

stretching the leg with considerable force once or twice a 
day after raising it slightly from its support. My assistants 
do this regularly during their morning and evening rounds. 




Fig. 127. — Fracture of the femur with extension apparatus (per- 
manent extension by weights) , and lateral traction applied under the 
sound limb. 



The advantages of the procedure are that the articular sur- 
faces are moved, though ever so slightly, that the frag- 



276 FRACTURES AND DISLOCATIONS. 

merits are replaced every day as perfectly as possible, and 
that callus-formation is hastened. 

After the patient has been placed in bed in the manner 
described, it becomes the surgeon's duty to keep the seat 
of fracture under constant supervision. This is facilitated 
by the fact that it is freely exposed and can be examined 
at any time. The displacement of the fragments is not 



Fig. 128. — Correct position for comparing the length of the two legs 
in fracture of the femur. The sound leg has been brought into sym- 
metric position as regards abduction and flexion, to correspond with 
the injured leg in the extension apparatus. 

always readily felt, however, on account of the enormous 
mass of muscles ; hence the length of the leg must be 
accurately measured from time to time and compared with 
that of the other side. It is not difficult to measure the 
injured thigh, say, from the lower edge of the patella to 
the anterior superior spine, without removing the bandage. 



FRACTURES OF THE LOWER EXTREMITY. 277 

The sound limb must, however, be measured in an exactly 
symmetric position. For this purpose the horizontal 
axis of the pelvis, L (\, the line connecting the two anterior 
superior spines, must first be determined. By the aid of 
a line drawn at right angles to it at the center and pro- 
longed downward, — for instance, a string or a tape-meas- 
ure, — the degree of abduction of the injured limb, which 
of course remains undisturbed within its dressings, can be 
measured, whereupon an assistant brings the sound limb 
into a similar position of abduction and flexion. Not un- 




Fig. 129. — Extension in fracture of the femur, when the knee-joint is 
contracted in flexion and the leg cannot be utilized for extension. 

til it is has been done are we ready to measure between the 
corresponding points on the sound leg and compare the 
result with that obtained on the injured side (Fig. 128). 

While this description appears somewhat complicated, 
the procedure, as a matter of fact, becomes quite simple 
after a little practice, and is exceedingly important if a 
favorable result is to be hoped for. 

Mensuration not infrequently shows that simple exten- 
sion, even with a heavy weight, is inadequate to overcome 



278 



FRACTURES AND DISLOCATIONS. 



the deformity. In such cases the old rule, to bring the 
lower fragment into the same position as the upper one, 
must be followed. The injured leg is brought into a posi- 
tion of moderate abduction and flexion, and extension by 
weights is applied both in the longitudinal direction and 
laterally, so as to limit the abduction of the upper frag- 
ment. s 

In children vertical extension is an excellent procedure. 
The fear of bringing about anemia of the leg and insuffi- 




Fig. 130.— Extension bandage in fracture of the left thigh with 
onter extension on the sound side and lateral traction on the upper 
fragment to limit abduction. 

cient development of callus by vertical elevation is, I am 
sure, unfounded except in the rarest cases. I have never 
experienced it, and the difficulty could readily be over- 
come by applying an elastic bandage (india-rubber drain- 
age-tube, see page 53) with slight pressure around the 
thigh above the seat of fracture. 

In new-born and very small children the best method 
of treatment consists in fixing the thigh in extreme flexion 



FRACTURES OF THE LOWER EXTREMITY. 279 



on the abdomen by means of a broad strip of adhesive 
plaster passed aronnd the entire body and thigh. 

A plaster-of-Paris dressing is sometimes indispensable 
if the patient is to be transported, or if delirium tremens 
makes its appearance. It is becoming more generally 
used, as it enables 
the patient to 
walk at an early 
period and per- 
mits ambulatory 
treatment. 

[In fracture of 
the shaft of the 
femur, the follow- 
ing dressing is a 
very satisfactory 
one : First exten- 
sion with heavy 
weights in a 
slightly flexed 
and abducted po- 
sition. The thigh 
is then fixed with 
four to six well- 
padded splints 
held in place by 
tapes which 
buckle. The ex- 
tension prevents 
shortening, the 
splints hold the 

movable fragments in good apposition. This dressing has 
the advantage over permanent plaster because it allows the 
daily examination of the seat of fracture. The posterior 
splint should be well padded to fit the normal curve of the 
femur and prevent the angular deformity which is not un- 
common in this direction, if not prevented. This dress- 




Fig. 131. — Vertical suspension for fracture 
of the femur in a child. The traction also pro- 
duces abduction of the injured leg, as shown 
by the oblique position of the pelvis. 



280 



FRACTURES AND DISLOCATIONS. 



ing is illustrated by Scudder. 1 In a large surgical clinic 
fractures of the shaft of the femur united with marked 
deformity very frequently come for treatment, demonstrat- 
ing the great tendency for not only overriding of the frag- 
ments, but marked angular deformity in these fractures. 
Yet we seldom observe this deformity in the large number 
of cases treated in the surgical wards, where this method 
of treatment with daily supervision is followed. — Ed.] 




Fig. 132. — Extension dressing with the limb in vertical position, 
and lateral traction to counteract the excessive flexion of the upper 
fragment. Child five years old (Else Hoffmann, 1896). Recovery 
without deformity. 

The principle of the ambulatory treatment of fractures 
of the femur is based on the fact that the bandage sup- 
ports the tuberosity of the ischium. The pelvis is thus 
supported and the leg hangs free, or extension may even 
be applied by the aid of buckles and elastic strips attached 
to the lower end of the splints, which in that case must be 
1 Loc. cit., p. 276. 



FRACTURES OF THE LOWER EXTREMITY. 



281 



longer than the leg. Hessinger has devised a very intri- 
cate apparatus of this kind. The 
simplest model, and one that has 
long been used in the treatment 
of various other injuries, such as 
diseases of the knee-joint, is the 
very useful splint introduced by 
a Liverpool physician, H. O. 
Thomas. Modifications of this 
splint devised by Brims, and 
similar complicated apparatus 
(Liermann, Roth), possess no ad- 
ditional advantages. 

Plaster-of-Paris dressings may 
also be used for this purpose, as 
Albers, Dollinger, and others 
have proved ; the technic of ap- 
plying them is, however, some- 
what more difficult, and care is 
accordingly necessary to avoid 
the production of pressure-sores. 
Albers has worked out a very 
useful method of applying a plas- 
ter cast without the interposition 
of a pad between the dressing and 
the skin. After thoroughly greas- 
ing the skin, he first applies a 
bandage inclosing the foot, leg, 
and region of the knee ; then a 
wide thick ring of plaster-of-Paris 
is fitted on the thigh so as to brace 
against the tuberosity of the is- 
chium. Vigorous extension is 
then applied to the foot and the 
rest of the thigh covered with a 
plaster bandage which is firmly 
attached to the first two pieces, 



Fig.133.— Thomas splint. 
The weight of the body is 
supported on the tuberosity 
of the ischium; the leg 
hangs free within the dress- 
ing. By means of a leather 
loop attached to the leg 
above the ankle and fast- 
ened below to the lower 
end of the splint, extension 
— elastic if desired — can be 
applied to the leg; other- 
wise the leg is simply fixed 
by means of roller bandages. 



282 FRACTURES AND DISLOCATIONS. 

which have by this time "set." (See Figs. 134 and 
135.) 

I should hesitate to recommend the method illustrated 
in figures 134 and 135, except to one possessing more 
than the usual experience in the use of plaster-of-Paris 
dressings. 




Fig. 134. — Method of applying a plaster-of-Paris dressing in frac- 
ture of the femur. That portion of the bandage which incloses the 
foot and leg and extends above the knee is completed, also the 
upper ring (Sitzring), which is made up of a number of plaster-of- 
Paris bandages and fits closely against the tuberosity of the ischium. 
The figure shows the injured leg. The patient is lying on a pelvic 
support, while an assistant exerts vigorous extension on the lower 
portion of the bandage, which is already set. The remaining middle 
portion of the plaster-of-Paris dressing is about to be applied. 

There is no doubt that a large proportion of fractures of 
the thigh can be treated by the ambulatory method from 
the beginning without endangering the result, and that the 



FRACTURES OF THE LOWER EXTREMITY. 



283 



method is greatly to the advantage of the patient's general 
condition ; 1 but in my opinion it is to be recommended 
only in very special cases, in which in spite of watchful 
care and nursing, the patient 
shows signs of suffering from 
two or three weeks' confine- 
ment in bed. The technic of 
this treatment is difficult ; there 
is a greater tendency to de- 
formity ; and it requires a su- 
pervision which the practis- 
ing physician is not always 
in a position to give. For 
the present the procedure can- 
not be said to be a suitable one 
in general practice (compare 
page 73). 

When a fracture has healed 
with marked deformity, the leg 
must be broken at the seat of 
fracture by means of osteoclasis 
or osteotomy, and extension 
treatment carried out with care- 
ful attention to every detail. 
In this way it is often possible 
to bring about partial correc- 
tion of considerable degrees of 
shortening if sufficiently heavy 
weights are used ; that is, from 
20 to 25 pounds. If a false 
joint has been formed, a good 
result may be obtained by an appropriate surgical opera 
tion. 




Fig. 135. — Ambulatory 
plaster-of -Paris dressing appli- 
cable in fracture of the middle 
or lower half of the shaft of 
of the femur. (See Fig. 134.) 



1 Ambulatory treatment of fractures of the upper half of the shaft 
is to be condemned without qualification, on account of the danger of 
deformity from flexion of the upper fragment. 



284 FRACTURES AND DISLOCATIONS. 

PLATE 58. 

Typical Displacement of the Fragments in Supracondylar 
Fracture of the Femur. — Fig. 1.— Supracondylar fracture, produced 
artificially on the cadaver ; postero-anterior view. 

Fig. 1 a. — Skeleton-preparation in the same position as figure 1. 
The displacement at the seat of fracture is evident; the lower fragment 
is more strongly flexed at the knee-joint by the action of the calf mus- 
cles. In figure 1 the vessels are shown as they lie astride, so to speak, 
of the projecting edge of the lower fragment (danger of gangrene). The 
sciatic nerve is also shown alongside of the vessels. 

(C) Fractures of the Lower End of the Femur. 

(Plates 58, 59, 63, Fig. 1.) 
At the lower end of the femur the epiphyseal line is 
found immediately above the prominences formed by the 
condyles (Plate 59). The following classification is useful : 

(a) Fractures of the femur above the condyles — supra- 
condylar fractures, usually transverse. 

(b) True epiphyseal separations, in youthful individuals. 

(c) Oblique fractures and T-fractures of the condyles. 

(d) Partial (split) fractures at the articular extremity. 
The number of fractures occurring at the lower end of 

the femur is much smaller than that of fractures observed 
in the shaft itself. 

(a) Supracondylar Fracture of the Femur (Fradura 
supracondylica). — Most of them are transverse fractures, 
although very acute oblique fractures, and even longitud- 
inal fractures, due to twisting of the lower portion of the 
shaft of the femur, have been observed (Plate 56, Fig. 3). 

Supracondylar transverse fractures present typical phe- 
nomena, both as regards the position of the fragments and 
their displacement ; the lower fragment, being acted upon 
by the powerful muscles of the calf, is flexed, and the two 
fragments override (Plate 58). The pull exerted by the 
muscles of the thigh produces shortening the degree of 
which is proportional to the amount of displacement and 
flexion of the lower fragment. 



Tdb.58. 





y I 



lig.lrf 



lig.l 



^K 



LUh.Anat E Reich held Miinchen. 



FRACTURES OF THE LOWER EXTREMITY. 285 

Examination. — Inspection discovers shortening of the 
thigh, swelling, and pain on movement at the seat of frac- 
ture. By palpation abnormal mobility at the lower end 
of the femur, at a point just above the condyles, is elicited, 
especially when the parts are moved in a lateral direc- 
tion. Crepitus is present if the fractured surfaces are in 
contact. 

The ends of the fragments can often be directly felt, the 
lower one high up in the popliteal space, the upper one 
in front. The knee-joint may also be injured at the same 
time. Anesthesia is desirable, both in making the exam- 
ination and in effecting reduction. 

Treatment. — The best treatment consists in permanent 
extension with weights. Moderate pressure by means of 
a roller bandage, or a loop connected with a second exten- 
sion apparatus pulling directly upward, may be applied 
against the lower fragment at the seat of fracture so as to 
keep it in a position of extension. If the displacement is 
very obstinate, it may be advisable to bandage the leg in 
flexion, after the fragments have been carefully replaced. 
It must not be forgotten that displacement of the lower 
fragment may produce pressure on the large vessels and 
on the sciatic nerve, and thus lead to serious complications 
(gangrene of the leg). 

[In fractures of the lower end of the femur the lower 
fragment is flexed by the calf muscles. For this reason 
the treatment of the fracture with the leg in flexion would 
seem to be, on the whole, the better method. Most author- 
ities agree to this. I have had excellent results after the 
reduction of the deformity by placing the flexed limb in 
a plaster dressing. At each subsequent dressing at inter- 
vals of about a week the limb can be re-dressed in plaster 
in a slightly more extended position, so that by the fourth 
week it is in a fully extended position. If there is much 
swelling about the knee (traumatic arthritis), the limb can 
be placed on a double inclined plane until the swelling 
subsides. — Ed.] 



286 FRACTURES AND DISLOCATIONS. 

PLATE 59. 

Figs. 1 and 2. — Showing the normal course of the epiphyseal line 
at the lower end of the femur and at the upper end of the tibia and 
fibula, in frontal and in sagittal section. 

Figs. 3 and 4. — Traumatic epiphyseal separation at the lower end 
of the femur, with backward displacement of the upper fragment. 
After a preparation in the College of Surgeons in London. In figure 
3 the normal outline is given as a guide. 

Fig. 5. — Transverse fracture through the lower end of the femur, 
with separation of the internal condyle. (After Anger. ) 



(b) Traumatic Epiphyseal Separation at the Lower 
End of the Femur. — The injury is not so very rare ; as 
the two cartilaginous portions of the bone which unite at 
the epiphyseal line possess a large surface of contact, and 
as the lower fragment is very short, it requires consider- 
able force to bring about this injury. For similar reasons, 
displacement of the fragments is, as a rule, only moderate, 
particularly as the periosteal investment may be partially 
preserved. Displacement, when present, is usually analo- 
gous to that observed in typical supracondylar transverse 
fractures. Occasionally, however, it is directly opposite 
in character (Plate 59, Figs. 3 and 4). It depends alto- 
gether on the nature of the injuring force and the direction 
in which it acts. The knee-joint rarely escapes (hemor- 
rhagic effusion). 

On examination, thickening and pain on pressure are 
discovered at the epiphyseal line. Sometimes the dis- 
placement may be felt, and soft crepitation may be made 
out. There is abnormal mobility, especially in abduction 
and adduction, movements that act like a lever on the leg. 

[According to Poland and others, reduction is fre- 
quently difficult and sometimes impossible in this epiph- 
yseal separation. In such cases one should operate. My 
colleague, Dr. Finney, has observed one case in which it 
was necessary to operate in order to reduce the dislocated 
lower fragment, with an excellent result. In effecting the 



Tab. ,5.9. 





Fig. 2. 




X^ 



Fig 5. 





Fig. 4 . 



Lith.Anst F. Reidihold , Stiuichen. 



FRACTURES OF THE LOWER EXTREMITY. 287 

reduction, Finney found that overextension of the lower 
fragment was first necessary, then traction with flexion. — 
Ed.] 

Treatment. — Careful reduction under anesthesia. Ex- 
tension or splint dressing. 

(c) Oblique Fracture and T-fracture of the Con- 
dyles {Fractura condyli, Fradura supracondylo-intercon- 
dylicd). — This is an extra- and intra-articular injury. The 
inner or the outer condyle may be broken off obliquely ; 
in still rarer cases a T-fracture {fractura supracondylo- 
intercondylica), analogous to T-fracture at the lower end 
of the humerus, has been observed. 

Diagnosis. — Lateral enlargement and pain on pressure 
at the region of the condyles ; lateral rocking movements 
are possible at the knee and are accompanied by crepitus ; 
sometimes sharp fragments of bone can be felt. Hemor- 
rhagic effusion in the joint. 

Treatment. — As there is danger of varus or valgus 
position developing at the knee-joint, great care is neces- 
sary in the treatment. The best method consists in exten- 
sion with compression about the joint, and, if necessary, 
puncture to evacuate the hemarthrosis ; passive motion 
should be begun early. 

(d) Partial (Split) Fractures at the Articular Ex- 
tremity. — These include separation of thin plates of 
bone from the cortex, corresponding to the insertions of 
the lateral ligaments, by severe twisting of the joint and 
split fractures separating pieces from the cartilaginous cap 
of the femur. They are pure intra-articular injuries, and 
will be discussed later on. 



4. KNEE=JOINT 

(A) Dislocation of the Knee-joint 

Intra-articular injuries of the ligamentous apparatus of 
the knee-joint are not as uncommon as true dislocations 



288 



FRACTURES AND DISLOCATIONS. 



of the joint. The latter are exceedingly rare, making up 
about 1 f of all dislocations. The leg may be dislo- 
cated : 

Forward (luxatio genu antica), by overextension, if the 
lateral and crucial ligaments have been torn. 

Backward (luxatio genu jiostica), or, rather, a forward 
dislocation of the condyles of the femur. 

Laterally (luxatio genu lateralis), bringing the leg into 
abduction or adduction. 

In addition, a number of varieties of incomplete dislo- 
cations occur. 





Fig. 136. — Forward dislocation 
of the leg. 



Fig. 137. — Backward dislocation 
of the leg. 



In every case the condyles of the femur can be more or 
less distinctly felt in an abnormal position. As it requires 
an enormous force to produce these dislocations, it is readily 
understood that they are often complicated with other 
severe injuries : compound fracture or dislocation. Pri- 
*mary lesion of the popliteal vessels, or pressure on the 
vessels when the dislocation remains unreduced for some 
time, may lead to gangrene. Reduction is said to be easy 
and is effected by traction and direct pressure. [Partial or 
complete rupture of the popliteal artery is the most fre- 



FRACTURES OF THE LOWER EXTREMITY. 289 

quent arterial lesion associated with dislocation, and should 
be constantly borne in mind. I observed it in one in- 
stance in which the posterior dislocation became reduced 
almost immediately after the injury. It was necessary to 
amputate the limb on the third day for gangrene. — Ed.] 

(B) Dislocations of the Patella. (Plate 60.) 

Dislocation of the patella is regarded as an unusual in- 
jury. Its attachments are not very firm, and it acts 
much like a sesamoid bone, as it lies between the liga- 
mentum patellae and the quadriceps muscle, but has very 
imperfect lateral attachments. 

(a) Outward dislocation of the patella is the most 
frequent form ; its occurrence is favored by the position 
of the patella, which overlies the outer condyle rather 
more than the inner. A tendency to valgus constitutes 
an especial predisposition to this dislocation. The dislo- 
cation is called incomplete when some portions of the 
articular surface are in contact ; complete, when the knee- 
cap is displaced in toto to the lateral side of the external 
condyle. The injury may occur while the knee is ex- 
tended or flexed ; in the former case the patella glides 
directly over the anterior surface of the lower edge of the 
femur outward. This form may also be produced when 
the knee is extended by the action of the quadriceps. 
AVhen the knee is flexed, the bone is displaced along the 
groove between the external condyle and the tibia. It 
is not rarely produced by direct violence acting from in 
front and within, as, for instance, when a man on horse- 
back receives a blow on the knee. The diagnosis is easy ; 
the knee-cap is absent from its normal position and is felt 
in an abnormal position. Reduction is effected by direct 
pressure, with the knee in extension and the thigh flexed 
at the hip, so as to relax the quadriceps muscle. 

(b) Vertical dislocation of the patella exists when 
the patella is turned through 90 degrees in such a way 

19 



290 FRACTURES AND DISLOCATIONS. 

PLATE 60. 

Dislocation of the Patella. — Fig. 1. — Specimen showing outr 
ward dislocation of the patella. The cartilaginous surface of the 
patella is in contact with the lateral surface of the external condyle. 
Anterior view. 

Fig. 2. — Preparation showing an internal vertical dislocation of the 
patella. The cartilaginous surface of the patella presents inward or 
toward the median line of the body. Inner view of the right leg. 

Fig. 3. — Specimen showing complete rotatory dislocation of the 
patella, produced by continuing the rotation from the position shown 
in figure 2. Anterior view of the right knee-joint*. 

Fig. 4. — Outward dislocation of the right patella in a man twenty- 
nine years of age (1880). The leg and region of the knee-joint are 
shown in marked flexion. The prominence of the patella to the outer 
side of the external condyle is very marked. 

that its edge comes to occupy the depression between 
the two condyles of the femur. We distinguish between 
inner and outer vertical dislocation, depending on whether 
the cartilaginous surface of the knee-cap presents inward 
or outward. Internal vertical displacement is prob- 
ably the more frequent of the two. It is produced by 
a direct violence acting from in front or from the side, and 
is also said to be produced by simple muscular action. 
The position of the patella is readily recognized when the 
leg is extended. 

(c) Complete Inversion of the Patella. — This is a 
rotation through 180 degrees, or, in other words, an ex- 
aggeration of the vertical dislocation just described. The 
articular surface of the patella presents forward. The in- 
jury is exceedingly rare. The diagnosis is difficult, unless 
accurate palpation is possible, and the twisting of the quad- 
riceps and of the ligamentum patellae can be recognized. 

(C) Fractures of the Patella. (Plates 61 and 62.) 

Fractures of the knee-cap are much more common than 
dislocations. They occur frequently in adults, usually in 
males under fifty years of age. 



7a/). 60. 




X s 





Fiq.l. 



^ 









Fig. 4% 




Via., 






FiaJ. 



LUh . Au.s/ /■' Reich /wM l/< i 



FRACTURES OF THE LOWER EXTREMITY. 291 

The patella in common with the entire region of the 
knee-joint is greatly exposed to injury. Fracture due to 
direct violence may follow a fall or a blow on the knee. 
Direct fractures sometimes assume the form of so-called 
radiating or stellate fractures ; that is, the patella sustains 
a blow on its flat surface and is shattered into several frag- 
ments, separated by radiating lines. The fragments usu- 
ally remain in good position. Direct violence may also 
lead to the production of oblique, longitudinal, and trans- 
verse fractures ; as, for instance, after a fall on the ground 
on a sharp stone, or the edge of the curb, etc. 

Indirect fractures are produced by contraction of the 
muscles. It is a common saying among the people that a 
drunken man rarely or never breaks any bones when he 
falls. This is quite true, for he falls to the ground like a 
sack. A sober man, on the contrary, will consciously, or, 
as is nearly always the case, in obedience to reflex stimuli, 
make some effort to prevent a fall whenever he stumbles. 
The sudden contraction of the quadriceps fixes the patella 
and may produce a fracture ; especially if the knee gives 
way at the same time, and the flexion at the knee-joint by 
means of the patellar ligament increases the tension on the 
patella while it is fixed above by the quadriceps muscle. 
A fracture by muscular action produced in this way usu- 
ally runs transversely through the middle, or slightly below 
the middle of the bone, corresponding approximately to 
the point where the body of the patella merges into the 
apex below. According to Bahr, this spot also corresponds 
to the point where that portion which is supported by the 
lower end of the femur joins the unsupported portion. 

The variation in the size and shape of the patella, 
which is considerable, has an important bearing both on 
the production of the fracture and on the examination of 
the limb. Hence comparison with the sound side must 
never be neglected. The density of the knee-cap is also 
subject to individual variations. 

The extent to which the strong aponeurotic structures 



292 FRACTURES AND DISLOCATIONS. 

PLATE 61. 

Fracture of the Patella.— Fig. 1. - Specimen of typical transverse 
fracture of the patella with extensive laceration of the aponeurotic 
layers on each side of the bone. Marked displacement of the frag- 
ments ; the knee-joint is wide open, and the lower end of the femur 
is exposed. The fringes from the tendinous investment formed by 
the tendon of the quadriceps project over the edges of the patellar 
fragments like a closely trimmed forelock on a pony's forehead. 

Fig. 2. — Specimen of transverse fracture of the patella, without 
laceration of the lateral aponeurotic structures. Although the knee is 
almost bent at a right angle, there is no displacement of the frag- 
ments. 

Fig. 3. — Same preparation as that seen in figure 2 ; seen from 
within, i. e. , behind. Below, are recognized the cartilaginous articular 
surface of the tibia ; above, the ligamentum patellae and the carti- 
laginous surface of the patella. The latter presents a transverse frac- 
ture through its middle. The edges of the cartilage are sharply out- 
lined. There is no displacement, as the lateral aponeurotic structures 
are uninjured. 

on each side of the knee-cap are involved in fractures of 
the patella is a factor of the greatest importance. As a 
rule, they are more seriously affected (torn) in indirect 
than in direct fractures. Even in direct fractures, how- 
ever, the tear in the lateral aponeurosis may be considera- 
ble, especially if the knee-joint continues to bend after the 
fracture has been produced ; that is to say, when the dis- 
tending and lacerating force reaches a maximum by con- 
tinued flexion at the knee-joint. 

These conditions have recently been subjected to a care- 
ful investigation by Konig. 1 

The importance of the tear in the lateral aponeurosis 
lies in the fact that it determines the degree of displace- 
ment, i. e., separation of the patellar fragments. In 
simple transverse fracture of the patella the gap is almost 

1 See Konig, Zur Entstehungsgeschichte der Verletzungen des 
Streckapparates vom Kniegelenk, Deutsche militararztl. Zeitschr., 

1897. 



Tab. 61. 





Fiq.2. 



Fig.3. 




Lith. Anst. F. Reiciiliolii Mimchm. 



FRACTURES OF THE LOWER EXTREMITY. 293 

nil; but if the lateral aponeuroses are extensively lacer- 
ated, the separation may be quite wide (Plates 61 and 62). 

The frequency of indirect fractures was formerly over- 
estimated ; it is true that the histories do not always fur- 
nish a reliable basis to determine the frequency of the in- 
jury. Bahr estimates the number of indirect patellar 
fractures at about 20^. 

The force that indirectly produces the fracture is obvi- 
ously exerted equally on the quadriceps tendon, on the 
ligamentum patellae, and even on the tuberosity of the 
tibia ; but fracture of the patella is by far the most com- 
mon result of such indirect violence. 

The symptoms are very clear, if, as is usually the 
case, the fracture runs transversely across the middle of 
the patella and produces some separation of the fragments. 
As the patella is completely inclosed within the capsule of 
the joint, this injury constitutes a pure intra-articular 
fracture. The extravasation of blood is into the joint and 
may be great enough to cause a good deal of tension. In 
recent cases the fragments can usually be pushed together 
until they come in contact and give forth distinct crepita- 
tion. If only a small piece from the edge of the patella is 
broken off, and in all cases in which the periosteal invest- 
ment of the knee-cap is preserved, the diagnosis may be 
somewhat more difficult. By careful examination, how- 
ever, both in recent cases and in cases of some standing 
that have not healed by bony union, some unnatural mo- 
bility of the fragments can usually be discovered, espe- 
cially if they are moved from side to side. 

Prognosis. — The prognosis of fractures of the patella 
depends chiefly on the nature and severity of the injury 
(stellate fracture ; transverse fracture ; or fractures com- 
plicated by extensive laceration of the ligamentary appa- 
ratus ; etc.) and on the method of treatment employed. 
The strength and resistance of the patient also have some 
bearing. Direct fractures, except transverse fractures 
associated with a great deal of separation, on the whole, 



294 FRACTURES AND DISLOCATIONS. 

PLATE 62. 

Fracture of the Patella. — Fig. 1. — Right leg of an elderly man 
with a transverse fracture of the patella, united by a broad mags of 
ligamentous tissue. The two fragments are separated by a broad 
interval running transversely across the bone. 

Fig. 2. — Young man (Gutsch, 1896) with bilateral fracture of the 
patella. The patient sustained a fall on both knees. About eight 
weeks after the injury, massage was begun and, as the illustration 
shows, the patient by that time was able to raise the right leg from 
the bed and hold it for a short time almost in extension, in spite of 
the marked separation of the fragments. As massage and other 
measures failed to secure a satisfactory result, I employed a bone- 
suture on both legs to bring the fragments together. The operation 
was therefore secondary and with a good result. 

Figs. 3 and 4. — Specimens of patellar fractures united by fibrous 
tissue. Seen in sagittal section. From the Museum of the College of 
Surgeons in London. 

Fig. 5. — Specimen showing a united stellate fracture of the patella. 
The fragments are united by a sufficient amount of callus, without 
displacement. 

have a better prognosis. As the strength, and to a certain 
extent the mobility, is often permanently impaired by 
fracture of the patella, the amount of economic disability 
depends greatly on the patient's calling. Persons whose 
work is light or who lead a sedentary life suffer less dis- 
ability than those engaged in active work ; although I know 
army officers of high rank who continue in active service 
in spite of the fact that they have a fracture of the patella 
with ligamentous union. In the case of a laborer, frac- 
ture of the patella usually means great disability. Even 
if both extension and flexion are restored approximately or 
even completely, the knee-joint and the entire leg in most 
cases remain weaker and less useful than before. Bahr made 
an accurate analysis of 44 old cases and found that 42 
(up to the time of his observation) had lasted on the average 
more than four years, and about 35 ^ showed complete 
disability so far as gaining a livelihood was concerned. 



Tab. 62. 







m 



i 









Fiff.£. 




FiaJ. 




Fig. 5. 




Liih.Ansi E ReichhoUl . Munch en. 



FRACTURES OF THE LOWER EXTREMITY. 295 

Treatment. — In this fracture more than in any other 
it has been observed that cases with marked separation of 
the fragments nevertheless heal with very satisfactory 
functional results, while fractures in which the position 
of the fragments is quite good sometimes produce intense 
and lasting impairment of function. The ultimate result 
depends largely on the behavior of the quadriceps. In 
many cases this muscle presents the appearance of a high 
degree of atrophy, due partly to prolonged disuse, and par- 
ticularly to reflex influences conveyed through the spinal 
centers. An important prognostic consideration is that 
this atrophy sometimes does not begin to develop until 
later, when the treatment is considered to be completed. 
To counteract the evil effects of prolonged immobilization 
and consequent disuse of the quadriceps, a method of treat- 
ment has recently been developed in which the attempt to 
approximate the fragments is abandoned and the condition 
of the quadriceps is maintained by massage (chiefly petris- 
sage and tapotement). Massage is performed daily, the 
fragments being pushed toward each other. The leg is 
placed on a splint with the knee in extension and the thigh 
flexed at the hip, because this position relaxes the quadri- 
ceps. While the value and logic of this procedure cannot 
be doubted, it must nevertheless be regarded as a somewhat 
one-sided treatment, and there is no good reason why it 
should not be combined with an attempt to bring about 
direct approximation of the fragments. 

The causes that are responsible for an unfavorable result 
in the treatment of fractures of the patella are many. The 
action of the quadriceps and consequent separation of the 
fragments is an important factor ; and no less important 
is the already mentioned atrophy of the muscle, which in 
many cases, even when the injury to the patella is slight, 
may be very great and even become permanent. The effu- 
sion of blood into the joint is another condition that tends 
to keep the fragments apart. It is also said that the vas- 
cular supply of the patella and its tendency to form new 



296 FRACTURES AND DISLOCATIONS. 

bone are less than in other bones. The truth of this state- 
ment may be doubted, however ; though it is true that the 
patella differs from other bones in the fact that its surface 
is formed on one side by a thick layer of cartilage, on the 
other by fibrous tissue. 

A form of interposition occurs which is of the greatest 
importance. The fibers of the outer fibrous layer are 
greatly lengthened and finally torn by the excessive ten- 
sion, and form overhanging fringes on the fractured sur- 
faces where they may catch and become interposed between 
the fragments. This condition increases the tendency to 
ligamentous union, even when the fragments are in good 
position (Plate 61, Fig. 1). 

In the treatment of this complication the obstacles re- 
ferred to must, of course, be avoided as completely as pos- 
sible : The leg must be fully extended at the knee and 
flexed at the hip, so as to relax the quadriceps. The knee- 
joint is fixed by means of a posterior splint, one made of 
plastic felt which is heated before it is fitted on, for in- 
stance. The fragments are to be approximated and freed 
from interposed tissues by vigorously rubbing them to- 
gether. They are then held in position by means of adhe- 
sive strips passing around the upper fragment like a loop 
and crossing each other on the posterior surface of the 
splint. Profuse extravasation of blood, if recognized with 
certainty, may be removed by puncture. The trocar should 
not be too small, so as to permit clots to pass through. 
The quadriceps should be subjected to petrissage and tap- 
otement once or twice a day, the movements being directed 
downward so as to push the upper fragment down. To 
counteract the evil effects of immobilization, faradic elec- 
tricity is used on the muscles, especially the quadriceps, 
with a weak current so as not to give pain. This should 
be combined with massage and, especially, gymnastic exer- 
cises. The patient is allowed to get up out of bed and 
use the leg at an early stage of the treatment. Painting 
with iodin is of no use, and may even be harmful. 



FRACTURES OF THE LOWER EXTREMITY. 297 

In many cases permanent extension has been found 
useful (Bardenheuer, Lichtenauer). A plaster-of-Paris 
dressing may also be used in cases with slight dislocation 
of the fragments. The patient is seated on the edge of 
the table, the knee overextended, and the thigh flexed at 
the hip. A trustworthy assistant seizes the upper fragment 
from above and forces it down as far as possible toward 
the lower fragment, which is pushed upward. While one 
holds the bone in the best possible position with his finger- 
tips, the plaster bandage is applied around the leg as close 
as possible to the assistant's fingers, which are not removed 
until the bandage has hardened. A dressing of this kind, 
if well applied, may be left in place for from one to two 
weeks — not longer, because massage should be begun at least 
after two weeks. The posterior half may be converted into 
a gutter splint and used for immobilization. 

When the patient is discharged, he should always be 
given a leather knee-cap with the injunction to wear it for 
some months. Appropriate exercises to be performed 
daily are ordered at the same time. 

The more perfect the approximation of the fragments, 
the firmer will be the union and the better the ultimate 
functional use. The most complete union of the fragments 
is by a kind of first intention of the fractured surfaces, and 
there is unquestionably enough proliferation of bone for 
this purpose. A knee-cap united by ligamentous tissue, 
even though the separation of the fragments is inconsider- 
able, never regains its normal strength. 

For this reason many surgeons advocate primary oper- 
ation ; in severe cases it is indispensable. The fragments 
may be united subcutaneously by various methods. Thus, 
an extra-articular method utilizes a kind of tendon suture 
passing through the quadriceps tendon and the ligamentum 
patellse close to the patella, thetwo ends being drawn together 
and tied in a knot over the knee-cap. An intra-articular 
method consists in introducing a silver wire or strong silk 
ligature in such a manner as to surround the patella in the 



298 



FRACTURES AND DISLOCATIONS. 



PLATE 62 a. 
Skiagraph of a Normal Adult Knee=joint ; Anterior View. 



femur - 



Epico/uh/Las Laieralis- 

Condylus Lateralis ferrwris 
CondyUis Lateralis tibiae. - 

Capituturn, fibulae 



Fibula 




E)vuvndyuts medtalis 

. Emtnentia, inlercondyloidea 
Condylus medtalis femoris 

CondyLus medtalis tibiae 

Maryo in/rayLenoidalis 



L/LrUL 



Fig. 138. 



sagittal direction (vertical) and draw the fragments to- 
gether in the form of a buried suture (Barker). The 
ligature is introduced by means of a long, appropriately 
curved needle, through two small incisions, one above, and 
one below, the patella. The old method by means of Mal- 
gaigne's hooks has now fallen into disuse. On the other 
hand, primary suture of the fragments, after exposing the seat 
of fracture and opening the joint, is constantly gaining ad- 
herents. It can, of course, only be intrusted to a practised 
surgeon, but has the distinct advantage of removing all the 
disturbing factors that interfere with complete union, and 
securing the nicest adaptation and fixation of the fractured 



Tab. 62 a. 




FBACTUME8 OF THE LOWER EXTREMITY. 299 

surfaces. The extravasation of blood is removed, the tags 
of fascia adhering to the fracture surfaces snipped away, 
holes are bored with as little damage as possible to the 
cartilaginous surface, and the wire sutures drawn through 
and twisted. Every step in the operation should be per- 
formed with carefully sterilized instruments, without 
touching the parts with the hand, which is so difficult to 
disinfect (Konig). Some surgeons confine their efforts to 
repairing the tear in the aponeurosis on each side of the 
knee-cap; but an additional suture through the bone un- 
doubtedly secures a better result. Instead of inserting 
sutures through holes previously drilled in the fragments, 
a single vertical loop of strong silver wire may be passed 
around the patella, after the manner of Barker, after the 
seat of fracture and the joint have been laid wide open by a 
curved incision running transversely over the entire joint. 
The wire is removed at some later time. I have fre- 
quently employed a bone suture secondarily after simpler 
methods of treatment (splints, adhesive strips, massage, 
etc.) had failed to secure the desired result. If, after the 
wound has healed and firm union has taken place, the 
patient is subjected to a careful course of massage and 
manipulation, correctly carried out, good results may be 
obtained in this way. 

Among particularly unfavorable events occurring after 
fracture of the patella the following should be mentioned : 

Failure of any kind of union between fragments. 

Union of the upper fragment with the anterior surface 
of the femur, a condition very rarely met with in old cases, 
and chiefly, in my experience, after direct, radiating pa- 
tellar fractures. Every attempt to flex the knee of course 
increases the separation of the fragments and only dimin- 
ishes the strength of the knee-joint. Permanent separation 
of the fragment from the femur, if there is true bony 
union, is probably never to be achieved ; an operation con- 
sisting in the interposition of a flap of muscle from the 
surrounding tissue may be tried. 



300 FRACTURES AND DISLOCATIONS. 

It happens comparatively often that the patella is 
fractured a second time ; the second fracture is produced 
by laceration of the ligamentous union, and usually occurs 
not long after the first fracture has healed, sometimes dur- 
ing the first weeks or months, and frequently at the first 
attempt to walk. A second fracture of the bone, at a 
point other than the old fibrous seat of fracture, has also 
been observed, but it is very rare. The treatment is the 
same as for a recent injury. 

[Powers, 1 in a very exhaustive consideration of the 
treatment of fractures of the patella, found that the major- 
ity of surgeons in this country and abroad were not will- 
ing to commit themselves to advise the operative treat- 
ment of every case of fracture of the patella. Nevertheless 
in almost every large surgical clinic in which the surgeon 
has a better control of the technic, operation is the rule 
rather than the exception. In my own experience it has 
been difficult to select cases for non-operative treatment, 
and in a few instances in which the separation of the frag- 
ments was very slight, and in which apparently we could 
bring about close apposition, we have found at the opera- 
tion torn shreds of ligament between the fragments, w T hich 
might have prevented solid bone union. The operative 
treatment of recent fractures of the patella unquestionably 
promises a better result than the non-operative treatment. 
In old fractures of the patella with separation of the frag- 
ments and functional disability of the limb the question of 
operation is sometimes more difficult to decide. In cases 
with wide separation of the fragments it may be necessary 
in order to approximate to do an extensive plastic opera- 
tion of the quadriceps muscle. The results of such an 
extensive operation are usually good as far as bony union 
of the patella is concerned, but it may be followed by con- 
siderable ankylosis of the knee-joint and atrophy of the 
muscle. For this reason the patient might prefer his for- 
mer condition, even if it were necessary to wear some 
1 Annals of Surgery, 1898. 



FRACTURES OF THE LOWER EXTREMITY. 301 

apparatus, because many would much rather have a weak 
but movable knee-joint than a stronger but partly anky- 
losed one. 

The question of operation in these more difficult cases is 
one to be decided in each case. The most important fact for 
the surgeon to know and the patient to understand is that 
the operation may be followed by an increase of restricted 
motion in the joint. In other cases in which the frag- 
ments can be approximated without a plastic operation on 
the quadriceps muscle the results are almost as good as 
after suture in the recent injury. The choice of time, how- 
ever, is quite an important one. If the fracture in the 
first instance has been treated in the usual non-operative 
manner, and after a period of from six to ten weeks it is 
found that bony union is not accomplished, then it is 
very bad to operate at this time, because an operation 
requires that the muscles and joint be kept at rest for a 
second period of six to ten weeks, thus greatly increasing 
the danger of ankylosis and atrophy of the quadriceps mus- 
cle. Conservative treatment having failed, we should 
abandon any attempt at further treatment of the fractured 
patella, and institute massage, passive motion, and use of 
the limb. When this has accomplished the restoration 
of complete joint motion and muscle tone, the time for 
operation has arrived. In a few cases we will find that 
although there is some separation of the fragments, the 
functional use of the limb is so good that many patients 
will be satisfied with the result and decline operation. If 
they are young individuals and wish to do much walking 
or heavy work, the operation should be urged, because 
in time, especially when the individual is active and the 
joint subjected to any unusual strain, the fibrous union 
will give way. 

In both recent and old fractures of the patella the joint 
as well as the muscles, especially the quadriceps, demand 
appropriate treatment as well as the fracture itself. This 
is frequently overlooked. — Ed.] 



302 



FRACTURES AND DISLOCATIONS. 



PLATE 62 b. 
Skiagraph of a Normal Adult Knee ; Lateral View. 



Femur 




Condylus media/is 

f'mwrts 



Emmcnlui 
Oderroi u/ytout^a- 



Condylus lateralis /emoris 
- Condylus merfialis tibiae 
Condylus laieraUs tibiae 

Margo infraglerwuiatis 



(D) Other Intra-articular Injuries of the Knee-joint 

(a) Separation of a Fragment from the Cartilagi- 
nous Covering of the End of the Femur (Plate 63, 
Fig. 1). — The arrangement of the bones entering into the 
construction of the knee-joint is somewhat different from 
that seen in a pure hinge-joint; when the knee is flexed, 
the leg is capable of a certain amount of abduction and 
adduction, and a considerable degree of rotation. This 
mechanism depends largely on the integrity of the crucial 
ligaments and of the semilunar cartilages. A force 
striking the knee in partial flexion, in such a way as to 



Tab. 62 b. 





FRACTURES OF THE LOWER EXTREMITY. 303 

compress it and force apart the bones that enter into the 
formation of the knee-joint, combined with a certain 
amount of lateral displacement or rotation, may cause the 
separation of a piece of the cartilage with a portion of 
the spongy bone to which it is attached. The force that 
produces such an accident is often very slight ; it may be 
nothing more than an awkward movement on the part of 
the individual. The fragment of cartilage has sharp 
edges, as it is broken in its entire thickness. The size 
and shape of the fragment vary from that of a bean to 
that of an almond. The injury can be produced experi- 
mentally on the cadaver (Kragelund). The fragment may 
be completely separated by the injury and act like a 
movable body (corpus mobile, "joint-mouse") within the 
knee-joint ; there are probably also cases in which the 
fragment maintains a certain amount of connection with 
the bone by means of fibers or a thin plate of bone, and 
gradually becomes completely separated by the repeated 
pressure and dislocating action incident to active move- 
ment, so that it eventually assumes the character of a 
movable body (" joint-mouse"). We refer to Volker's 
Arch. f. klin. Chir., vol. xxxvu. The fragment must 
of course be removed by operation according to estab- 
lished surgical principles. 

(b) Injuries of the Semilunar Cartilages (Plate 63, 
Fig. 2). — These include dislocation, and laceration or rup- 
ture of the semilunar cartilages, which may occur without 
any accessory injuries. Up to the year 1892, 43 cases 
had been reported (Bruns). The internal semilunar car- 
tilage is affected twice as often as the external. Complete 
dislocation, with separation of both anterior and posterior 
insertions of the cartilage from the capsule of the joint, 
does not occur, but partial dislocation, forward, backward, 
or to one side, of one or the other cartilage from traumatic 
loosening of its attachment has been observed. Separa- 
tion of the anterior insertion is the most common form. 
Abnormal mobility of the cartilages from gradual loosen- 



304 FRACTURES AND DISLOCATIONS. 

PLATE 63. 

Fig. 1. — Separation of a fragment of cartilage from the surface of 
the internal condyle of the femur. The illustration shows the loss of 
substance in the end of the femur and the separated fragment. 

Fig. 2. — Rupture of the internal semilunar cartilage in the knee- 
joint. 

Figs. 3 a and 3 b. — Specimens from a compression-fracture at the 
upper end of the tibia. The articular surface is viewed from above ; 
the bones of the leg from behind. The fracture occurred in a young 
woman and was produced by a fall from the top of a loaded hay- 
wagon. The condyles of the femur exerted pressure on the upper sur- 
face of the tibia. The woman died of acute sepsis which had its origin 
in a torsion-fracture of the same tibia in its lower half. (See Langen- 
beck's Archiv, vol. xli, p. 357.) 

Fig. 4. — Elderly man with a fracture of the left tibia, near its 
upper extremity (fractura tibiss infracondylica) . Union with the de- 
formity known as the O-leg. The fracture was produced by the kick 
of a horse. 



ing of their insertions has been rarely observed. A solu- 
tion of continuity in the semilunar cartilage is rare. 

The injuries are produced by active rotation of the end 
of the femur while the knee is flexed, thus extruding the 
cartilage. A sound normal joint is therefore a prerequisite 
condition, and the injury is accordingly observed most fre- 
quently in England among athletes (football players, etc.). 

The symptoms of a recent luxation vary in intensity 
in accordance with the degree of distortion which produced 
the injury. There is always intense pain in the affected 
side of the joint, which is in partial flexion and can be 
flexed but not extended. There is a good deal of effusion 
and swelling, with a considerable degree of functional 
disturbance. In old or habitual luxation, pain and inter- 
ference with movement occur paroxysmally, being evi- 
dently caused by a sudden displacement and compression 
of the cartilage. 

On examination we frequently find, if the cartilage has 
been torn from its anterior insertion, a flat movable body 



Tab. 6.3. 




r' r 





Fiq.3 a 




Fig.3b 




Firj.l. 



Fitj. 



2 



l.Uh. Anst.F Reich Iw Id Miinchm 



FRACTURES OF THE LOWER EXTREMITY. 305 

within the cleft of the joint. This body disappears in the 
depths of the joint during flexion and becomes more.promi- 
nent during extension. Both the patient and the surgeon 
may be able to feel it slipping in and out distinctly. 
More rarely the site of the cartilage in the articular cleft 
is broader or deeper, and sensitive to pressure, conditions 
that are due to permanent displacement of the fragment 
of semilunar cartilage into the interior of the joint. If 
there is much effusion, examination may be impossible. 
As regards the differential diagnosis, it may be very 
difficult to distinguish the cartilage from a free movable 
body within the joint. 

Treatment. — In recent cases the cartilage should be 
replaced as completely as possible ; a slight pressure ban- 
dage applied, and later replaced by a plaster-of-Paris cast 
fitted on while the leg is in extension. The cast is left on 
for six weeks, and after that period the patient should pro- 
tect his knee by wearing a leather knee-cap. In old or 
habitual cases an attempt should be made to obtain fixation 
by means of buried sutures. Ideal results are sometimes 
achieved by this means, better than by complete extirpa- 
tion of the semilunar cartilage, which is often performed 
and has been highly lauded, although it is not followed 
by any marked impairment of function. 



5. LEG 

(A) Fracture of the Leg at the Upper End 

I. Isolated Fractures at the Upper End of the Tibia 

(a) Compression-fracture of the Upper End of the 
Tibia (Plate 63, Fig. 3 ; see also Plate 3, Fig. 1).— This 
fracture is produced by sudden compression of the artic- 
ular extremity of the tibia by one or both of the condyles 
of the femur. It may follow a fall on the feet from a great 
height, as, for instance, in mining when the elevator shoots 
to the bottom and the passengers strike on their feet, or a 
20 



306 FRACTURES AND DISLOCATIONS. 

fall from a hay-wagon. I once saw this fracture produced 
by jumping off a bicycle. 

The injury consists in an infraction of the upper artic- 
ular surface of the tibia with depression of the fragments 
and, sometimes, fissures on the surface of the bone. The 
latter occur particularly in compound injuries when torsion 
takes place through the medium of the fibula (see Plate 
63). In severe cases (see Plate 3) the upper articular end 
of the extremity may be broken into two or three pieces 
and the shaft firmly wedged in the spongy tissue of these 
fragments. 

Examination. — The appearances of a severe distortion 
or contusion of the joint are manifest, the injury being 
wholly or at least in great part intra-articular. Accord- 
ingly there is an effusion, first hemorrhagic and later serous, 
into the joint ; movements of the joint are painful ; and 
abnormal rocking movements are possible in most cases. 
The upper end of the tibia appears enlarged laterally and 
there is characteristic pain on pressure. If only one-half 
of the articular surface is involved in the fracture, either 
varus or valgus deformity is apt to result. The inner half 
— that corresponding to the internal condyle of the femur 
— is fractured more frequently than the outer half, hence 
varus is common and may become permanent. There is 
also great danger of secondary arthritis deformans. 

Treatment. — The injury is best treated by means of 
permanent extension with weights, the foot being sup- 
ported on a sliding rest, supplemented if necessary by lat- 
eral traction extension by means of a loop to prevent varus 
or valgus deformity by overcorrection. Massage and 
passive movements should be begun early. 

(b) Transverse Fracture of the Upper Extremity 
of the Tibia (Fractura tibice infracondylica). (Plate 63, 
Fig. 4.) — This is a rare fracture. It is produced either 
by direct violence, — for example, by the kick of a horse, 
as in the case from which our illustration is taken, — or 
more rarely by indirect violence, the causative force being 



FRACTURES OF THE LOWER EXTREMITY. 



307 



the same as would under other 
circumstances result in frac- 
ture of the lower end of the 
femur or luxation of the knee- 
joint. It is a transverse frac- 
ture of the upper articular 
portion of the tibia. When 
the line is more oblique, the 
joint itself may be affected 
directly and primarily. Even 
in a transverse fracture the 
joint is usually involved (hem- 
orrhagic effusion). 

The diagnosis is based on 
lateral enlargement of the 
bone, pain on pressure, and 
abnormal rocking movements. 
It is best to have the patient 
anesthetized. 

Treatment. — I prefer per- 
manent extension with weights, 
the seat of fracture being left 
exposed, so as to permit com- 
pression and massage to be 
begun early both at the seat of 
fracture and at the joint. If 
there is a tendency to varus 
or valgus deformity, the same 
preventive measures must be 
adopted as in compression- 
fracture of the tibia. 

(c) Traumatic Epiphyseal 
Separation at the Upper 
End of the Tibia (Plate 59, 
Figs. 1 and 2). — This is a 
rare injury ; but if a history 
of severe contusion at the 




II 



Fig. 138 a. — Skiagraph of a 
knee-joint and leg from a child 
3 years old. The epiphyses 
are easily recognized. 



308 FRACTURES AND DISLOCATIONS. 

upper end of the tibia in a child is obtained, the surgeon 
should bear its possibility in mind. A positive diagnosis 
can be arrived at only under anesthesia, by demonstrating 
abnormal movability and characteristic crepitus. For the 
rest, especially for the question of treatment, the reader 
is referred to sections a and b. As there is little tendency 
to displacement, an ordinary splint dressing may also be 
employed. 

(d) Tear-fracture of the Tuberosity of the Tibia. — 
This is a very rare injury observed in adults, and espe- 
cially in children, when it takes the form of an apophyseal 
separation. As in all fractures of apophyses the tendency 
to displacement is considerable : the fragment in this case 
is drawn upward by the quadriceps acting through the 
patella and ligamentum patellar. The patient finds it 
impossible to extend the leg at the knee-joint ; the frag- 
ment is felt under the skin, and is readily moved in any 
direction. The patella above is intact ; the knee-joint is 
not necessarily involved, but usually contains an effusion 
of blood. 

A treatment similar to that used for fractures of the 
patella is applicable. The best method consists in effect- 
ing thorough reduction, which may be done by overexten- 
sion, and then nailing the fragment in place. 



II. Isolated Fractures at the Upper End of the Fibula 

Fracture of the head of the fibula may be produced by 
direct violence, such as a blow or the kick of a horse ; or 
indirectly by a powerful contraction of the biceps femoris 
(fracture by muscular action). The external popliteal 
nerve may be injured. 

The tendency to displacement is not constant. If de- 
formity is present, the best and safest procedure is to cut 
down on the injured bone and unite the fragments with a 
silver wire. In other respects the treatment should follow 
general principles. 



FRACTURES OF THE LOWER EXTREMITY. 309 

(B) Fracture in the Middle Portion of the Leg 

I. Fracture of Both Bones in the Region of the Diaphysis. 

(Plates 64 and 65.) 

This injury is very common. It is usually produced 
by direct violence, such as being run over, the two bones 
being broken at about the same level. An isolated frac- 
ture of the lower portion of the tibia may first be produced 
indirectly by torsion of the body when the foot is fixed, 
and followed by secondary fracture of the fibula which is 
unable alone to support the weight of the body. The 
fibular fracture is in the form of a bending fracture, and 
usually occupies a higher level (Plate 65, Fig. 1). Oblique 
fractures, whether by bending or by torsion, are, generally 
speaking, more unfavorable — i. e., exhibit more tendency 
to displacement — than transverse fractures. The sharp 
upper fragment is frequently driven against the skin and 
may perforate it, especially when the line of fracture 
extends in front as far as the crest of the tibia in the form 
of the mouthpiece of a flute. 

The diagnosis is usually quite easy, as there is no dif- 
ficulty in demonstrating abnormal mobility, crepitus, and 
deformity. Rotatory displacement of the lower fragment 
may be recognized by noting the position of the patella 
and of the foot as compared with the other side, and by 
running the finger along from the crest of the tibia above 
and from below as far as the seat of fracture. On the 
other hand, it is often difficult to determine the point 
where the fibula is fractured. Nowadays with the aid of 
Rontgen rays it can be ascertained with certainty. 

To determine the presence of abnormal mobility at the 
suspected seat of fracture it is well to have an assistant 
who should firmly fix the knees with both hands, the 
patient lying flat on the table or in bed. The surgeon 
meanwhile with one hand, say the left, feels for the seat 
of fracture, while with the other (the right) he seizes the 
leg at the ankle and alternately performs abduction and 



310 



FRACTURES AND DISLOCATIONS. 



adduction. If the surgeon experiences unusual difficulty 
and the data obtained by other methods of examination 
are uncertain, it is a good plan for the surgeon to brace the 
suspected seat of fracture and the left palpating hand 
against his own body, for instance, the thigh, while he 
attempts to move the leg with the right hand. 




Fig. 139.— Old fracture of the leg 
with deformity ; the bones are bowed 
backward. 



Fig. 140. — Lateral bow- 
ing in an old fracture of the 
leg. 



Treatment. — All possible care should be exercised to 
reduce the fracture ; it may be done by vigorous extension 
on the injured foot and counterextension of the thigh or 
pelvis, with direct manipulation at the seat of fracture. If 
the fracture is transverse, however, the displacement is 
very apt to recur. The tendency for the upper or, in 



FRACTURES OF TH FT LOWER EXTREMITY. 311 

exceptional cases, the lower fragment to injure the skin in 
front where it is thin must be combated by position, the 
limb being slightly overextended at the seat of fracture. 
A certain amount of care is needed to bring about cor- 
rect reduction and maintain the fragments in position. The 
rule that when the leg is in the proper position, the anterior 
superior spine, the inner border of the patella, and the 
inner side of the great toe lie in the same straight line 
does not hold in the majority of normal legs (see Plate 64, 




Fig. 141. — Extension and counterextension in fracture of the leg. 
A weight has been attached to the leg by means of a loop of gauze to 
counteract the forward displacement of the upper fragment at the seat 
of fracture. 



Fig. 3). It is better to place the two legs in such a posi- 
tion that the patella will be perfectly horizontal, and then 
to fix the injured leg in a position to correspond with the 
shape and direction of the sound leg. In this way the 
very objectionable dislocatio ad peripheriam will be avoided. 

Knee and foot must be included in the dressing ; the 
former in extension, the latter at a right angle to the leg. 

During the first week a so-called Volkmann's T-splint 
of strong tin, or two lateral flexible splints, may be used 



312 FRACTURES AND DISLOCATIONS. 

PLATE 64. 

Fractures of the Leg. — Fig. 1. — Specimen of united fracture of 
both bones of the leg with marked displacement of the fragments. 
Both bones were broken at about the same level, suffered the same 
kind of displacement, and all the four fragments are connected to each 
other by abundant callus-formation. (Pathol. Inst., Berlin.) 

Fig. 2. — Specimen of a united fracture of both bones of the leg. 
Slight displacement. Good recovery. The tibia was fractured in the 
lower, the fibula in the upper, half. 

Fig. 3. — Line to determine the correct position of the fragments in 
fracture of the lower leg. It is seen that in the normal leg the line 
connecting the great toe with the anterior superior spine approximately 
bisects the patella. 

Figs. 4 and 4 a. — Isolated fracture of the tibia with upward dis- 
placement (dislocation) of the head of the fibula. The anatomic speci- 
men, figure 4 a, is intended as an aid to understanding the conditions. 
Figure 4 is copied exactly from nature ; it is the leg of a man twenty- 
nine years of age. The injured leg was 3 cm. shorter than the sound 
leg. 

with advantage ; the splints must be well padded so as to 
avoid pressure at any point, especially in the region of the 
heel. 

In many cases of this kind I consider it absolutely in- 
dispensable to anesthetize the patient at the end of the first 
week and, after a thorough examination, to replace the 
fragments in position. At this time a well-padded plaster 
bandage is very useful. A second revision, followed by 
the application of a well-fitting plaster-of-Paris dressing, 
without padding, should be held about a week later. In 
this way lateral deviations may readily be avoided. If 
there is rotatory displacement, even greater care is neces- 
sary. A rotatory displacement in fracture of the upper half 
of the leg usually takes the form of inward rotation of the 
lower fragment. Should a tendency to overextension at 
the seat of fracture be overlooked, a permanent deformity, 
consisting in backward bowing of the bones, may result. 
This deformity is particularly apt to develop during the 



Tab- 64. 




Iig.1. 




FRACTURES OF THE LOWER EXTREMITY. 313 

application of the plaster-of-Paris dressing, when the leg 
is supported only by extension applied to the foot and 
counterextension if insufficient force is used. It is, there- 
fore, a good plan to raise the bone at the seat of fracture 
by means of a loop or with the hand, while the dressing is 
being applied. 

If a sharp fragment of bone should press against the 
skin, a Malgaigne hook may be used to keep it in position. 
This is a special instrument which is fastened within the 
dressing, and, by means of a steel point which is extruded, 
exerts direct pressure on the offending fragment. Effec- 
tual reduction, appropriate position, and, in many cases, 
the employment of permanent extension with weights will, 
however, do all that is necessary and enable the surgeon 
to dispense with this instrument, which at one time en- 
joyed considerable repute. 

A permanent extension dressing is equally applicable in 
fractures of the leg and yields very good results (Barden- 
heuer). In fractures exhibiting a tendency to recurring de- 
formity, permanent extension applied immediately after re- 
duction is a very useful dressing for the first week, and 
secures the best possible position until it is time to apply a 
rigid dressing ; but it must be constantly and carefully 
looked after and, if necessary, supplemented by lateral 
traction (see page 72). 

May not a plaster-of-Paris dressing be applied in the 
very beginning of the treatment of a fracture of the leg? 

This question must be answered, as many physicians 
find it the most convenient and practicable method. First 
of all, the reader is referred to what has been said in the 
general part of this work (pages 63 and 64). There is no 
doubt that treatment with plaster-of-Paris dressings from 
the very beginning is perfectly feasible, but it requires 
higher technical skill and may involve great danger. A 
well-fitting and well-padded dressing, even a plaster-of- 
Paris dressing, may be applied at the very beginning if the 
fracture is recent when the patient first presents him- 



314 FRACTURES AND DISLOCATIONS. 

self for treatment. If only one or two hours have elapsed 
since the injury, the swelling is as yet inconsiderable, and 
if the fragments are accurately replaced and a tight bandage 
is applied, any marked degree of subsequent swelling is, 
as a rule, prevented. In such a case, therefore, even a 
primary plaster-of-Paris dressing might do no harm ; but 
in view of the possibility of many accidents, partly owing 
to the stupidity of the patients themselves, a primary 
plaster-of-Paris dressing should be employed only when 
the surgeon possesses technical skill and can see his patient 
every day. 

Ambulatory Treatment of Fractures of the Leg (So= 
called Walking Dressing). — Of recent years various pro- 
cedures have at different times been recommended with a 
view to allowing the patient to walk about while under 
treatment for fracture of the leg. Splints may be used 
similar to Thomas' splint (see page 281), such, for instance, 
as those designed by Brans ; extension may be applied to 
the leg by means of elastic strips attached to the low T er end 
of the splint ; or the leg is allowed to hang free but at the 
same time fixed by specially devised splints, the patient 
supporting his weight on the tuberosity of the ischium when 
he walks. The plaster-of-Paris dressings act in a similar 
way, or at least reach as far as the middle of the thigh, 
the knee being slightly bent (Krause, Korsch). Others 
recommend splints or plaster-of-Paris dressings that do not 
quite reach to the knee, thus immobilizing only the leg and 
foot and permitting free movement at the knee-joint 
(Schmid, Dollinger, and others). The technic of these 
dressings includes perfect reduction, and the application 
of a thinly padded bandage with a maximum amount of 
pressure to keep the fragments in good position. The 
dressing must be rigid enough to prevent displacement of 
the fragments even when the patient is walking. The 
pressure is in part applied over the region of the upper- 
most fragment ; as a precautionary measure the dressing 
may be renewed once or twice. With a bandage of this 



FRACTURES OF THE LOWER EXTREMITY. 



315 



kind the patient is said to be able to walk about without 
pain and without the aid of crutches. 

For the present I adhere to my opinion that procedures 
of this kind and any other ambulatory dressings are not 





Fig. 142.— Plaster-of -Paris 
dressing in ambulatory treat- 
ment of fracture of the leg, 
either at the middle or above 
the middle of the bones. 



Fig. 143. — Plaster-of-Paris 
dressing in ambulatory treat- 
ment of fracture of the leg below 
the middle of the bones, espe- 
cially fracture of the ankle. 



appropriate in general practice, though they may give ex- 
cellent results in the hands of a few surgeons. 

After the bones have united, baths, douches, massage, 
and active and passive movements are required to restore 



316 FRACTURES AND DISLOCATIONS. 

the function. If a bony prominence remains at the seat 
of fracture and requires correction, because it is painful or 
otherwise distressing, it should be removed with a chisel ; 
the bone should be exposed by turning back a flap of 
tissue. 

The prognosis of fractures of the leg depends entirely 
on the treatment. If it is correctly carried out from the 
beginning, the fracture will be completely healed and 
function fully restored unless very special complications 
supervene. Experience teaches us, however, that this re- 
sult is obtained in less than half the cases. Deformity 
and edema at the seat of fracture, rigidity of the joints, 
etc., often continue for a long time or permanently to inter- 
fere with the victim' s power to earn a living. 

[In my experience fractures of the shaft of the bones of 
the leg (one or both) are, of all fractures, the most appro- 
priate for the plaster dressing. For the first week or ten 
days the knee-joint should be included in the dressing; 
after this the knee-joint may be left out, unless there is a 
tendency to displacement. These patients can be allowed 
to walk with crutches in the majority of instances after 
the first few days. The most important point, next to the 
perfect reduction and proper fixation of the fragments, is 
more frequent change of dressing; the plaster dressing 
should be changed at least once a week, and the limb 
bathed and rubbed. — Ed.] 

II. Isolated Fracture of the Shaft of the Tibia 

(Plate 64, Figs. 4 and 4 a.) 
It has already been remarked that fracture of both 
bones of the leg begins in many cases as a fracture of the 
tibia alone, that of the fibula occurring secondarily. 
Fracture of the tibia may be produced by bending, as Avell 
as by torsion. In the operation of osteoclasis for the cor- 
rection of rachitic legs it is often observed that the tibia 
alone gives way, and that fracture of the fibula requires a 
second effort on the part of the operator. 



FRACTURES OF THE LOWER EXTREMITY. 317 

Isolated fracture of the tibia may therefore be produced 
by indirect or by direct violence ; if the latter, by a blow, 
a fall, the kick of a horse, etc. 

The diagnosis of isolated fracture of the tibia, if it is 
oblique and associated with some degree of displacement, 
is not difficult, even though the intact fibula acts as a kind 
of splint. If the fracture is transverse, however, and the 
fragments are in good contact without displacement, the 
diagnosis is difficult. In the absence of other signs the 
surgeon must rely on a certain crackling noise elicited by 
forced movements, with pain on pressure and on striking 
the bone. If the isolated fracture of the tibia is associated 
with marked displacement, the fibula must also be involved. 
Either the bone is broken and the fragments are displaced 
as those of the tibia, or, as happens particularly in frac- 
tures of the upper half of the shaft of the tibia, the 
fibula is dislocated, the head of the bone being displaced 
upward (Plate 64). The mistaken diagnosis of isolated 
fracture of the tibia is the more easily made from the fact 
that the fibular fracture, instead of being at the same 
level with the tibial fracture, is quite frequently at some 
distance from it, usually at a much higher point (Plate 
64, Fig. 2). 

Treatment. — The fragments should be replaced as per- 
fectly as possible ; in a recent case, any displacement of 
the fibula that may exist can at the same time be corrected. 
To keep the fragments in position a well-fitting plaster-of- 
Paris or splint dressing suffices. In transverse fractures 
without displacement the ambulatory treatment is more 
easily carried out than in fractures of both bones of the 
leg. 

III. Isolated Fracture of the Shaft of the Fibula 

This is a very rare injury that can only be produced by 
violent direct force, as the fibula is protected by a robust 
layer of muscles. The injury is treated on general prin- 
ciples. 



318 FRACTURES AND DISLOCATIONS. 

(C) Fracture of the Lower End of the Leg 

I. Fracture of Both Bones at their Lower Ends 

In this section I shall repeatedly speak of forced move- 
ments of the foot, of the foot being bent over sidewise, etc. 
In addition to dorsal and plantar flexion, we also speak 
of a lateral movement or bending of the foot toward the 
outside, described as abduction or pronation, and to the 
inside, described as adduction or supination. The move- 
ment concerns the posterior segment of the tarsus, the 
astragalo-tarsal articulation, and the robust lateral liga- 
ments of the astragalo-crural articulation. The foot is ro- 
tated about a line that corresponds approximately to its 
long axis. Finally an injury may also be produced by 
rotation of the foot, which really consists in a rotation of 
the leg about a vertical line corresponding to the longitu- 
dinal axis of the leg, and is also known as inversion and 
e version. 

(a) Supramalleolar Fracture of Both Bones of the 
Leg (Fraetura cruris supramalleolaris). (Plate 65.) — This 
fracture merits special consideration. It may be com- 
pared to supracondylar fractures occurring at the lower 
end of the femur or of the humerus, and especially that 
occurring at the lower end of the forearm. 

The fracture is produced by direct violence, or indirectly 
by sudden abduction or adduction of the foot ; it is also 
frequently produced by torsion of the foot, so that the 
line of fracture may extend into the ankle-joint, 

^ The diagnosis of supramalleolar fracture as such is not 
difficult. The displacement, which is usually quite con- 
siderable, may produce a talipes valgus (Plate 65, Fig. 3), 
or, as I have observed in a number of cases that healed 
with deformity, a varus-position or curvature of the leg in 
the so-called O-shape (Plate 65, Fig. 4). The lower frag- 
ment may also be displaced backward, causing the foot to 
drop at the heel. 

Treatment. — After the fragments have been replaced; a 




Fig. 144. — Skiagraph of a su- 
pramalleolar fracture of the tibia 
(torsion-fracture) with great dis- 
placement of the fragments, pro- 
duced by a fall from a bicycle. 
When the patient presented him- 
self for treatment, nine weeks 
after the accident, the fragments 
were firmly united with callus. 
The tip of the upper fragment 
was removed by operative means, 
after which the injury Avas treated 
by massage and passive move- 
ments, the patient wearing a 
special apparatus to relieve the 
ankle-joint. 




319 



Fig. 145. — Skiagraph of a su- 
pramalleolar spiral fracture of 
the tibia. There is also a frac- 
ture of the fibula at its upper ex- 
tremity. Frd. Helm, fifty-two 
years of age, 1897. When the 
patient was admitted, three weeks 
after the injury, the deformity 
here depicted was found at the 
seat of fracture, with marked in- 
version of the foot. The position 
of the fragments was corrected as 
well as possible ; later the pro- 
jecting point of the bone was re- 
moved with a chisel. The frac- 
ture healed slowly with good ul- 
timate position of the limb. 



320 FRACTURES AND DISLOCATIONS. 

PLATE 65. 

Fractures of the Lower End of the Leg.— Fig. 1. — Torsion- 
fracture of the lower end of the tibia with typical bending fracture of 
the fibula. The specimen was taken from a patient who had sus- 
tained a compression-fracture of the same tibia ( Plate 63, Figs. 3 a and 
3 6). The torsion -fracture extends into the astragalo-crural articula- 
tion. 

Fig. 2. — Torsion-fracture of the lower half of the tibia, fibula in- 
tact. The ankle-joint is not involved. 

Fig. 3. — Supramalleolar fracture of both bones of the leg, with 
great deformity, producing a talipes valgus. Bony union. 

Figs. 4 a and 4 b. — Supramalleolar fracture of both bones of the 
right leg, with considerable deformity, producing a talipes varus or 
O-shaped leg. Figure 4 a is a posterior view of both limbs in parallel 
position. Figure 4 b is an anterior view of the injured leg alone. 
(Christian Sass, forty-nine years old, 1896. ) 

careful dressing must be applied, immobilizing the seat of 
fracture, the ankle-joint, the foot, and, at first, including 
also the knee-joint. In applying the dressing, care must 
be exercised to avoid overcorrection. I have seen varus 
deformity — L e., a position of adduction — result from a 
fracture Avhich at first presented a displacement in the 
sense of an abduction, all because the limb was fixed too 
long in an overcorrected position by the pressure bandage. 
Backward displacement of the foot along with the lower 
fragment is to be specially guarded against. 

In badly united fractures the degree of deformity is at 
once recognized by inspecting the foot from behind, espe- 
cially if the two legs are placed in parallel positions. The 
only way to correct the deformity is by osteoclasis or oste- 
otomy at the seat of fracture ; and the operation should by 
all means be performed, in the hope of avoiding or at least 
diminishing the functional disability which otherwise be- 
comes permanent. 



Tab. 6S 



/^.... 






Eig.2. 



FigJ. 






Fig. 4- a 



Fig. 4b 



Lith 



FRACTURES OF THE LOWER EXTREMITY. 321 

Fractures of the Ankle (b and c) 

These fractures form a group which is of the greatest 
practical importance. They are produced indirectly by 
forcible pronation or supination of the foot at the ankle- 
joint, or by sudden rotation (eversion or inversion). We 
may accordingly distinguish supination-, pronation-, and 
inversion- or eversion-fractures. For practical purposes, 
however, fractures of the ankle are divided into disloca- 
tion-fracture (Stromeyer) and sprain-fracture (v. Burck- 
hardt). The former are combined with simultaneous dis- 
location of the foot, the latter only with distortion of the 
ankle-joint. These two groups have the following points 
in common : They are produced by indirect violence; they 
are combined with a fracture of one or both bones of the 
leg at their lower extremity ; the ligamentary apparatus of 
the ankle-joint is involved, the injury ranging from simple 
distortion to complete luxation with extensive laceration 
of the ligaments (v. Burckhardt). 

Fractures of the ankle by direct violence are clinical 
curiosities. In the treatment of all fractures of the ankle 
the fundamental fact that we are dealing with a joint-frac- 
ture must never be lost sight of (see page 74); hence sys- 
tematic passive and active movements with massage must 
be employed. First, however, the fragments must be re- 
placed as accurately as possible if any deformity exists. 

Deformity is always present in dislocation-fractures, 
while in sprain-fractures the deformity is apt to be slight 
or absent. Reduction is effected by vigorous extension 
applied to the heel, followed by sudden compressing, forc- 
ing the foot into its proper position. The positions of the 
bones should be re-examined and, if necessary, again cor- 
rected at the end of the first week. Anesthesia is usually 
required. 

(b) Typical Fracture of the Ankle (Pott's Frac- 
ture) (Plates 66, 67). (Fractura malleoli interna cum 
fractura fibulae supramalleolaris, or Fractura malleolaris 
tibice et supramalleolaris fibulce.) — A typical fracture of 
21 



322 FRACTURES AND DISLOCATIONS. 



PLATE 66. 



Typical Fracture of the Ankle (Pott's Fracture).— Fig. 1 

Illustrates an anatomic preparation after the artificial production of a 
fracture of the ankle-joint. The joint has been opened in front and 
freely dissected. The internal malleolus is seen to be broken, although 
still attached to the tarsus by the strong deltoid ligament. We also 
see the two small fragments torn loose from the tibia by the anterior 
and posterior tibiofibular ligaments. The external malleolus is dis- 
placed outward, away from the tibia. This displacement is made pos- 
sible by fracture of the fibula above the ankle, permitting considerable 
outward excursion of the external malleolus. 

Fig. 2.— Frontal longitudinal section of the leg and foot, after the 
artificial production of a typical fracture of the ankle. The internal 
malleolus, which is broken off from the tibia, is seen alongside of the 
astragalus. The supramalleolar fracture of the fibula is particularly 
well shown, with the angular deformity of the bone at this point which 
is responsible for the pronounced valgus position of the foot. 



the ankle may be compared to a typical epiphyseal fracture 
of the radius; just as in the latter, the mode of production, 
the symptoms, and the principles on which the treatment 
is based present certain typical features. That the fibula 
should be included in a fracture of the ankle is readily 
understood on account of the anatomic relations ; i. e,, the 
intimate connection between the tibia and the fibula. 

Etiology. — A typical fracture of the ankle is usually 
produced by a sudden fall of the body outward when the 
foot is fixed, or by sudden eversion of the foot. The frac- 
ture can also be produced on the cadaver as follows : The 
leg is placed in such a position that the outer surface lies 
flat on the table, the foot and ankle projecting over the 
edge; the operator suddenly throws the weight of his 
entire body on the foot so as to bring about abduction, the 
internal malleolus is torn loose, and, if the force is con- 
tinued, the fibula gives way a little above the outer mal- 
leolus at the point where the leg projects over the edge of 
the table. 

Precisely the same conditions are found in the majority 



Tab. 66. 





A 







Fiy.Z. 



Fit 



LUh. Anst tl Reichhchi. Munc'ncn. 



FRACTURES OF THE LOWER EXTREMITY. 



323 



of fractures of the ankle. The abduction or pronation 
of the foot at the astragalo-crural articulation throws great 
strain on the internal lateral ligament or deltoid ligament. 
If the movement is continued, the tip of the internal mal- 
leolus and not the ligament, as a rule, gives way. As the 
next step the foot as 
a whole, and especial- 
ly the heel, is forced 
against the external 
malleolus, and the 
fibula gives way at its 
weakest point a few 
inches above the an- 
kle. In a number of 
cases the weight of 
the body on the ab- 
ducted foot after the 
internal malleolus has 
been fractured pro- 
duces a bending and 
finally a fracture of 
the fibula, as that bone 
alone is unable to sup- 
port the weight of 
the body. 

Symptoms. — Ac- 
cordingly, the tip of 
the internal malleolus 
in a typical fracture 
of the ankle is ab- 
normally movable and 
often displaced down- 




Figs. 146 and 147. — Compound fracture 
of the ankle in a woman twenty-five years 
of age. Reduction was finally accom- 
plished after division of the interposed 
skin. Under strict aseptic treatment re- 
covery ensued with good function at the 
ankle-joint. 



ward, while the fibula 
presents a fracture above the external malleolus. By 
holding the foot in one hand and fixing the leg above the 
region of the ankle, abnormal lateral movements, especially 
abduction or pronation of the foot, are possible. In most 



324 FRACTURES AND DISLOCATIONS. 

PLATE 67. 

Fracture of the Ankle. — Fig. 1. — Normal epiphyseal lines at the 
lower end of the tibia and fibula. 

Figs. 2 a and 2 b. — Fracture of the ankle, healed with deformity — 
i. e. , severe traumatic pes planus, after a typical fracture of the ankle. 
Anterior and posterior views (Lohrke, male, thirty-nine years old, 
1896). 

Figs. 3 a and 3 b. — Backward subluxation of the foot in typical 
fracture of the ankle. Figure 3 a represents the living foot, figure 3 b 
the skeleton (Schon, male, twenty-eight years old, 1895). 

cases the foot is already in an abnormal position — a kind 
of valgus position or eversion. 

The region of the internal malleolus, or, more correctly, 
the edge of the fractured tibia, sometimes forms such a 
marked prominence that the integument over it, which is 
very thin, becomes greatly stretched and threatens to give 
way. If laceration takes place and a compound injury is 
produced, the condition not rarely becomes a true disloca- 
tion (dislocation-fracture). The lower end of the tibia 
may project through the skin to such an extent as to require 
free division of the interposed skin before reduction can be 
effected. 

The characteristic angular deformity above the external 
malleolus is always present in the fibula to a greater or 
less extent. Abnormal mobility of the fragment can often 
be determined by palpation, although not without consider- 
able pain to the patient. The upper end of the fragment 
can occasionally be reduced by pressing on the tip of the 
malleolus, effecting a kind of rocking movement, which is 
sometimes accompanied by palpable crepitation. It is 
extremely important to keep the anatomic details of this 
fracture well in mind. The fragment of the internal mal- 
leolus is often extremely small. The fracture of the fibula 
as just described is, of course, possible only if the ligaments 
uniting the tibia and fibula at their lower extremities have 
been divided. These ligaments may be torn, but there is 



Tah.67- 




t iff. i . 





Fiq.Xrv 



Ficf.£/j 






W*WtY**'>Aw^ 




Ficj.J 






/ 



i! 



9 ; 




^VV/.-j' /; 



/<//(. .i//.v/ A' Heiriiiwki. Miinchm. 



FRACTURES OF THE LOWER EXTRE3IITY. 



325 



always a possibility of a fragment being torn loose from 
the articular end of the tibia. In this way a fragment of 
variable size, sometimes from an oblique fracture extend- 
ing into the joint, may be torn away in front by the ante- 
rior tibiofibular ligament, and occasionally also behind by 
the posterior tibiofibular ligament (see Plate 66). It is 





Figs. 148 a and 148 b. — Typical fracture of the ankle before and 
after reduction. Wilhelm Hamann, male, aged fifty-two years, stum- 
bled and fell on his right leg. Typical ankle-joint deformity. In 
Fig. 148 a the fractured and outward displaced tip of the inner mal- 
leolus, the supramalleolar fracture of the fibula, and the displacement 
of the lower fragment are well shown. Under anesthesia reduction 
was successfully accomplished (Fig. 148 b). The direction of the 
bones at the seat of fracture is good, though the lower fibular fragment 
still forms a prominence. Recovery with good functional result. 

only after the connection between the tibia and the fibula 
has been severed, that the fibula can be displaced laterally 
until a bending- fracture is produced. 

It is a point of clinical importance that the function in 



326 



FRACTURES AND DISLOCATIONS. 



these cases is not always completely abolished. Indi- 
viduals with unusual grit, sometimes even children, may 
be able to limp along quite a distance. 

Prognosis. — Typical fracture of the ankle, even when 
it is not compound, always represents a grave injury. It 
is a true articular fracture and doubly important from the 
fact that the affected joint must support the entire weight 





Fig. 149. — Rontgen-ray pictures of a typical fracture of the ankle of 
some standing, with a skiagraph of the sound leg. Saklowsky, female, 
forty years old, sustained this fracture fourteen years before pictures 
were taken. The fracture healed without medical treatment of any 
kind in the course of a year. Typical deformity. Increasing diffi- 
culty in walking and standing. Operation : Osteotomy of the internal 
malleolus and fibula, followed by correction of the deformity. A 
week later another attempt to correct the position of the foot was 
made under anesthesia. Uneventful recovery with considerable im- 
provement in position. 

of the body. Gross mistakes are still made in its treat- 
ment, with grave consequences to the function of the joint 
and the individual's ability to earn a living for the rest of 
his life. 

Treatment. — First and most important is complete re- 



FRACTURES OP THE LOWER EXTREMITY. 327 

placement of the fragments. The foot as a whole must be 
forced over toward the tibia by a movement of adduction. 
It was formerly taught that the foot should actually be 
brought into the varus position so as to correct the valgus 
deformity that is present, or to prevent its occurrence. 
But this procedure is neither necessary nor advisable, pro- 
viding only the position of the foot is completely corrected 
and the angular deformity of the fibula above the external 
malleolus is made to disappear. To effect this, the fibula 
must be forcibly pushed against the tibia ; or the two mal- 
leoli may be forcibly brought together. In a severe com- 
pound injury of this kind I replaced the lower fragment 
of the fibula and then nailed it to the lower shaft of the 
tibia. If there is backward displacement, it must be cor- 
rected at the same time by drawing the foot forward. 

After reduction has thus been effected, if necessary 
under anesthesia, the foot and leg must be placed in the 
proper position. It is of the utmost importance to keep 
the foot at a right angle with the leg and otherwise in correct 
position, so that when the patient begins to walk, the foot 
will rest on the ground in the normal manner. During 
the first days a splint dressing — either a tin or a Avire 
splint — is best ; later, a plaster-of-Paris splint or two 
plaster-of-Paris gutters made by dividing the dressing and 
not too thickly padded should be used. In a short time 
the patient can leave his bed and begin to use the leg. 

During the first- two weeks the dressing should be re- 
moved at intervals of three or four days, and after that 
every other day, to permit massage and passive movements 
of the joint. The position of the foot must be constantly 
watched, for I once saw a very unfavorable position of the 
foot result from careless bandaging several weeks after the 
injury, although the position during the first few weeks 
had been quite good. Even much later, when the fracture 
is firmly united, the surgeon's attention should be directed 
to this point, and when the patient is discharged he should 
be given an appropriate brace to prevent the formation of 



328 



FRACTURES AND DISLOCATIONS. 




talipes valgus. I have known a great deal of good to re- 
sult from the use of medico-mechanical apparatus. 

To combat an obstinate tendency to talipes valgus a 
dressing after the manner of the old Dupuytren's splint is 
of advantage. Dupuytren's dressing consists of a splint 
applied to the inner side of the leg and 
a cushion covering the leg from the 
knee to the ankle-joint. An interval 
is thus left between the splints and the 
region of the internal malleolus and 
foot, permitting the latter to be drawn 
over toward the splint and secured by 
a few turns of a roller bandage. 

The advantage of this dressing in 
counteracting outward displacement of 
the foot and the production of talipes 
valgus is at once apparent. 

If the limb is in a bad position when 
the patient presents himself for treat- 
ment, and the fragments have for weeks 
been fixed in their incorrect position, 
appropriate operative measures must at 
once be resorted to. If it is found im- 
possible to break up the adhesions that 
have formed, osteotomy of the fibula 
at the seat of fracture, and of the in- 
ternal malleolus as well, must be per- 
formed in order to bring the foot into 
the correct position. The after-treat- 
ment is then the same as for a recent 
fracture. 

In these cases with bad deformity it 
is useless to hope for gradual improvement by the patient's 
becoming accustomed to the condition. The interference 
with the movement and position of the heel and of the re- 
maining bones of the tarsus, produced by the injury in the 
ankle region, are more likely to become aggravated as time 



Fig. 150. —Du- 
puy tren ' s dressing 
for typical fracture 
of the ankle with 
deformity, produc- 
ing a traumatic tal- 
ipes valgus. A cush- 
ion is interposed be- 
tween the splint and 
the side of the leg, 
so that the free pro- 
jecting end of the 
splint may be util- 
ized to fix the foot in 
the proper position. 



FRACTURES OF THE LOWER EXTREMITY. 329 

goes on. If the patient refuses operation, some improve- 
ment may be secured by means of a brace so applied as to 
correct the position as much as possible, to fix the parts 
and relieve the foot of the weight of the body. Our main 
object is, and always must be, to avoid the occurrence of 
deformity during the time that the bones are uniting and, 
if deformity develops in spite of our efforts, to correct it 
by active measures as soon as possible. 

[This " typical fracture of the ankle " corresponds to 
that called Pott's fracture in most English and American 
text-books. The majority of authorities agree that after 
complete correction of the deformity the foot should be 
overcorrected and placed in a varus position. I have 
not at hand, nor have I ever seen, Dupuytren's original 
communication with regard to his splint, but I have always 
understood that the chief object of the splint was over- 
correction and the foot in a varus position. In the sur- 
gical clinic of the Johns Hopkins Hospital this over- 
corrected position has always been employed, and we have 
yet to observe an immediate or ultimate bad result, while 
quite a number of cases (old fractures united with de- 
formity) have been admitted to the clinic with the result- 
ant flat-foot when this overcorrected position was not em- 
ployed. My OAvn experience teaches me, then, emphatic- 
ally to favor the overcorrected position. 

Flat-foot following Pott's fracture is not uncommon. 
In many cases the functional disability can be relieved by 
a proper shoe and a flat-foot brace. The operative results, 
even in the worst cases of deformity, are most satisfactory. 
The older operation was an osteotomy of the tibia with 
forced correction of the deformity (Trendelenburg's oper- 
ation). Osteotomy at the seat of fracture in the fibula is 
a much simpler procedure, and with rare exceptions will 
overcorrect the deformity. After this latter operation the 
foot is almost restored to its normal appearance, while after 
Trendelenburg's osteotomy there results a rather unsightly 
curvature of the lower end of the tibia. — Ed.] 



330 



FRACTURES AND DISLOCATIONS. 



PLATE 67 a. 
Skiagraph of a Normal Ankle=joint ; Anterior View. 



TibicL 



MalleoUis merticULs- 



Os naoicutare - 




Fibula. 



Articulatw LibwfibuLarLs 



x- \\\ ■ MalleoUis lateralis 
Talus 



(c) Fracture of Both Malleoli (Fractwra malleolorum, 
Fraciura malleoli externi et interni). — If the foot is adducted 
or supinated until the external malleolus gives way, with 
the production of a talipes varus, the internal malleolus 
may also be fractured. For mechanical reasons the shaft 
of the tibia does not become fractured as in the typical 
fracture of the ankle, as we can readily understand. 

This injury is very much less frequent than the typical 
fracture of the ankle described under b (Pott's fracture). 
We may here include certain other rare fractures, such as 
fractures by rotation of the foot at the astragalo-crural 
articulation about a vertical axis corresponding to the long 
axis of the leg. 

The diagnosis requires only a careful examination, and 



Tab. 67 a. 




FRACTURES OF THE LOWER EXTREMITY. 



331 



the treatment is analogous to that of typical fracture of the 
ankle. 

(d) Epiphyseal Separation at the Lower Extrem- 
ities of the Bones of the Leg (Plate 67, Fig. 1).— This 
is a rare injury t which is only observed in children. It 




Fig. 151 a and 151 b. — Skiagraphs showing a severe epiphyseal 
separation at the lower end of the tibia, with fracture of the fibula 
before and after reduction. Wilhelm P., sixteen years old, fell down- 
stairs and injured his right ankle. On admission (December 2, 1899) 
the leg presented extreme deformity as in a typical fracture of the 
ankle. The diagnosis of epiphyseal separation was made by the char- 
acteristic symptoms and the skiagraph (Fig. 151 a). Reduction was 
successfully accomplished under anesthesia; recovery with very good 
functional results. Skiagraph (Fig. 151 b). 



sometimes occurs during the forcible correction of severe 
grades of club-foot. The separation is recognized by the 
presence of abnormal mobility above the region of the 
ankle and by cartilage crepitus. The treatment demands 
complete rest and, later, exercises. 



332 



FRACTURES AND DISLOCATIONS. 



PLATE 67 b. 

Skiagraph of the Normal Astragalo= tarsal Articulation and 

Tarsus; Lateral View. 



Calcaneus 
MaUeolas Lateralis 



Sustentaculum taU 



Os cubotdeum 



Os rnetatarsale 




Tlfiia 
Malieoius medialte 



Os naolculare 



* - - 1 - Os cunciforme J 



■ Os melaiarsale, 1 



II. Isolated Fracture of the Tibia, and III. Isolated Fracture 
of the Fibula at their Lower Extremities 

These two classes include isolated supramalleolar and 
malleolar fractures of one or the other of the two bones. 
They are produced indirectly in the same manner as the 
fractures of the ankle which have just been minutely de- 
scribed, except that the force required is less intense or 
the application less prolonged. They may also be pro- 
duced by direct violence through the agency of a sharp 
body striking the bone or by the individual's falling 
against such a body. 



Tab. 67 b. 








tip* 




FRACTURES OF THE LOWER EXTREMITY. 333 

Isolated fractures of one malleolus are relatively com- 
mon, while isolated supramalleolar fractures are rare. 

Examination sometimes fails to yield positive results, 
but the pain elicited by abduction or adduction of the foot, 
or by pressure, or by a blow, will at least suggest the pres- 
ence of a fissure. Doubtful cases must be treated as if 
fracture were present. The treatment should follow the 
general principles laid down for the treatment of fractures 
of the ankle. 



6. ASTRAGALO=CRURAL ARTICULATION 

Movements of the foot include flexion and extension at 
the astragalo-crural articulation, and pronation and supi- 
nation at the astragalo-tarsal articulation. In pronation 
and supination the full connection between the astragalus 
and the bones of the leg is maintained, the movements 
affecting only the articular connections between the astrag- 
alus and the os calcis and those between the talus [astrag- 
alus] and the os naviculare [scaphoid]. 

AVhen external violence produces forced movements of 
the foot ending in a sprain or dislocation, the foot performs 
one of the following movements : Flexion (plantar flexion) 
or extension (dorsal flexion) about a horizontal frontal axis ; 
pronation (abduction) or supination (adduction) about a 
horizontal sagittal axis, corresponding to the long axis of 
the foot ; eversion (tip of the foot turned outward) and 
inversion (tip of the foot turned inward), or rotation about 
the vertical axis of the leg. 

(a) Dislocations at the Astragalo-crural Articula- 
tion (Plate 68). — These are the true luxations of the foot. 
We may have a forward, by excessive dorsal flexion, or 
a backward dislocation, by excessive plantar flexion. The 
position of the foot is so characteristic (see Plate 68) that 
the diagnosis is made without any difficulty. The dislo- 
cation is reduced by direct pressure on the tibia, forcing 
it forward or backward, with simultaneous flexion in one 



334 FRACTURES AND DISLOCATIONS. 

PLATE 68. 

Dislocation of the Foot at the Astragalo=crural Articula= 
tion. — Figs. 1 and 1 a. — Specimen showing backward dislocation of 
the foot. The astragalus is observed behind the external malleolus, 
and between the two bones are the tendons of the peronei muscles. 
The foot is shortened, the posterior portion, corresponding to the heel, 
being lengthened. Figure 1 a shows the appearance in the skeleton. 

Figs. 2 and 2 a. — Specimen showing a forward dislocation of the 
foot. The astragalus is in front of the bones of the leg the tendons of 
the peronei muscles are stretched, the foot is lengthened, the part cor- 
responding to the heel being shortened. Figure 2 a shows the condition 
in the skeleton. 

direction or the other, according to the kind of dislocation 
present. If one of the tarsal bones is fractured, it is of no 
importance. Lateral dislocations are not possible without 
the presence of fracture of the ankle. 

(b) Dislocation at the astragalo-tarsal articula- 
tion, or so-called luxatio sub talo, when outward, is pro- 
duced by excessive pronation, when inward, by forced 
supination of the foot. Anterior and posterior dislocations 
at this joint are even more rare. The diagnosis may pre- 
sent some difficulties, but can usually be made by carefully 
palpating the bony prominences, by finding the movement 
of the astragalo-crural articulation to be normal, and by 
noting the altered shape of the foot, especially if the exam- 
ination is made under anesthesia. 

Reduction is very difficult and requires complete relax- 
ation of the muscle. It may be accomplished by appro- 
priate manipulation and pressure. 

Isolated Dislocation of the Astragalus (Talus) 

The astragalus may be dislocated in various directions. 
The mechanism is extremely complicated, and has never 
been fully explained. The injury is accompanied by 
great deformity ; the astragalus may be felt more or less 
distinctly through the skin. The tibia approaches the sole 



Tab. (> 8. 




Fig.l. 







Tig.1. 





LWi. Anst F. ReirhhoUl, Mimctien . 



FRACTURES OF THE LOWER EXTREMITY. 335 

of the foot and sometimes articulates directly with the os 
calcis. 

Reduction is difficult. If it cannot be effected by man- 
ipulation, it must be brought about by operative means 
both in this and in the above-mentioned dislocations. The 
good results often obtained if the asepsis is perfect are 
somewhat remarkable considering that the astragalus loses 
part of its connections and blood-supply. 



7. THE FOOT 

The skeleton of a foot should always be at hand, not 
only in studying the injuries of the foot, but also when an 
individual case is to be examined. In addition, the in- 
jured foot must of course be carefully compared with its 
fellow, providing the latter is uninjured. During inspec- 
tion the two feet should be placed parallel, so that their 
long axes correspond with the observer's line of vision, 
and enable him to compare them accurately both from in 
front and from behind. In addition to minute palpation, 
not omitting a single detail, it is well to take impressions 
of the sole of the foot by having the patient step on smoked 
paper and fixing the paper with a 5 ^ solution of shellac 
(or compound tincture of benzoin). 

(A) Fracture of the Tarsal Bones 

(a) Fracture of the Astragalus. — Fracture of the 
astragalus rarely occurs as an isolated injury, being almost 
always combined with injuries of the knee-joint or of the 
tarsus. Dislocation of the astragalo-crural articulation is 
often accompanied by infractions, tear-fractures, and frac- 
tures of the astragalus. Fracture of the astragalus, espe- 
cially of the neck, has also been observed in severe frac- 
tures of the os calcis. The appearances obviously depend 
on the complicating injury, and are not always very dis- 
tinct. The diagnosis may be made by the visible altera- 



336 



FRACTURES AND DISLOCATIONS. 



tion in the shape of the foot ; swelling of the dorsum ; pain 
following pressure on the head or neck of the bone, the 




Fig. 152. — Compression-fracture of the right os calcis in a young 
man, nineteen years old. Seen from above and from the outer side. 
(Artificial. ) 



presence of thickening ; narrowing of the tarsal fold, inter- 
ference with dorsal flexion ; and, finally, mensuration with 

a pair of compasses. 
Treatment is based on 
general principles. 

(b) Fracture of the 
Os Calcis. — The frac- 
tures are classified ac- 
cording as they involve 
the body of the bone or 
one of its processes, which 
are described as the poste- 
rior, or tuber calcis • the 
anterior, or capitulum cal- 
canei, or sustentaculum ; 
and the lateral, or pro- 
cessus trochlearis sive 
inframalleolaris. 

Compression - fracture 
of the os calcis is produced 
by falling on the feet or awkward jumping. The etiology is 
usually quite typical. Masons, roofers, miners, and paint- 
ers furnish the largest contingent. The bone is demol- 





Fig. 153. — Compression-fracture of 
the left os calcis, produced by a fall 
on the foot. Wilhelm Rell, 1895. 
Posterior view. 



FF AC TUBES OF THE LOWER EXTBEMFTY, 



337 



ished by the astragalus being driven against it. As a rule, 
a longitudinal fracture is found in the upper surface of the 
bone. In severe cases numerous additional lines of frac- 
ture are observed, so that the bone is literally demolished. 
In a severe case the following characteristic symptoms are 
present : The 
bone is enlarged 
in its lateral di- 
ameter, flattened, 
and painful. The 
malleoli, espe- 
cially the inter- 
nal malleolus, are 
nearer the sole 
of the foot than 
they should be ; 
pes plan us is often 
present. Move- 
ment at the as- 
tragalo-crural 
joint is not af- 
fected, while the 
movement at the 
articulation con- 
cerned in prona- 
tion and supina- 
tion of the foot is 
limited. Some- 
times the injury 
is bilateral. 

In old cases 
the diagnosis is 
sometimes easier than in a recent case, on account of the 
callus and secondary changes. In addition to the lateral 
enlargement of the os calcis which may reach 2 cm., the 
grooves on either side of the tendo Achillis are obliterated 
by edema ; the muscles of the calf are atrophied ; walking 
22 




Fig. 154. — Typical compression-fracture of 
the os calcis. Skiagraph. The alteration in 
the shape of the anterior half of the bone is 
distinctly shown; the distance between the 
upper and lower surfaces is shorter than nor- 
mal. Disability in this case was permanent. 



338 



FRACTURES AND DISLOCATIONS. 



is greatly interfered with; there is constant pain; and 
characteristic anomalies in the position of the foot, with 
depression of the malleoli, are noted. 

This fracture is much more common than was formerly 
supposed. The injury is often mistaken for a severe 
sprain. The most accurate examination is indispensable. 
The prognosis of this fracture is not very favorable. 
Even when it is recognized early, the functional use of the 
foot is, as a rule, greatly impaired for some time. If the 

case is recognized very 
late, the individual's abil- 
ity to earn his living may 
be greatly diminished for 
a long time or even per- 
manently. This is no 
doubt in part due to the 
fact, established by more 
recent methods of inves- 
tigation, that the fracture 
in many cases is not con- 
fined to the os calcis, but 
involves other adjoining 
bones, such as the malleoli 
and the neck of the as- 
tragalus. 

Treatment. — Unless 
the fragments are replaced 
and the foot remains fixed 
for a long time in good position, traumatic flat-foot is apt 
to develop. The heel should not be subjected to exces- 
sive pressure at first on account of the danger of fat em- 
bolism ; later on, compression, combined with massage 
and passive movements, is of distinct advantage. 

Fracture of the tuberosity of the os calcis is not com- 
mon. It is due to muscular action, such as sudden con- 
traction of the muscles of the calf, or to direct contusion. 
It also complicates the clinical picture of severe compres- 




Fig. 155. — Fracture of the tuber- 
osity of the os calcis by a fall on the 
feet, four weeks old. Female, forty- 
eight years of age. There is marked 
upward displacement of the fragment. 
Operation. Recovery. 



FRACTURES OF THE LOWER EXTREMITY. 



339 



sion-fractures of the body of the os calcis. The fragment 
is displaced upward by the action of the muscles of the 
calf. It can be replaced by flexing the knee, and fixed 
to the body by means of a nail. At first the foot should 
be dressed in extension, with the leg flexed at the knee. 
Under certain conditions it may be necessary to drag the 
displaced frag- 
ment down forci- 
bly and fix it by 
means of a nail, 
after dividing the 
shortened Achil- 
les tendon by an 
oblique cut, and 
uniting the ends 
with a suture so 
as to lengthen the 
tendon. 

Fracture of the 
Median Process, 
or Sustentaculum 
Tali.— This in- 
jury consists in 
fracture of the 
bony process at 
the inner surface 
of the os calcis, 
which supports 
the astragalus 
and contributes 
to the formation of the groove for the transmission of the 
tendon of the flexor hallucis. Accordingly there is vio- 
lent pain on pressure at this point, the astragalus is dis- 
placed inward and downward, and the foot is in valgus 
position. There is some interference with flexion and 
extension of the foot at the astragalo-crural articulation ; 
abduction and adduction are greatly limited. 




Fig. 156. — Fracture of the second metatarsal 
bone. Skiagraph from a sailor twenty years 
old injured in marching. Typical "swelled 
foot." Transverse fracture about the middle 
of the second metatarsal, with lateral displace- 
ment. The diagnosis could only have been 
made by means of the Rontgen rays. 



340 FRACTURES AND DISLOCATIONS. 




Fig. 157. — Fracture of the fifth metatarsal bone (X-ray). Fielitz, 
male, twenty-four years old. The injury was produced by a very heavy 
piece of iron falling on the foot. It is therefore a direct fracture or 
crushing-fracture of both phalanges of the big toe. Soft parts un- 
injured; marked swelling. Ordinary dressing; recovery. 



FRACTURES OF THE LOWER EXTREMITY. 



341 



In old cases a bony thickening is usually observed about 
the sustentaculum below the internal malleolus. In anat- 
omic specimens the sustentaculum is often found united by 
callus with the posterior median process of the astragalus. 

This isolated fracture of the sustentaculum is rare. It 
may be produced by great violence when the foot is in 
supination or in 
pronation, such 
as making a mis- 
step in going up- 
stairs or down- 
stairs, jumping, 
or falling from a 
horse. In most 
fractures of the 
sustentaculum 
the body of the 
os calcis and the 
internal malleo- 
lus are also frac- 
tured. 

Fracture of the 
anterior process 
of the os calcis 
may form part 
of a compres- 
sion-fracture of 
the body of the 
bone. As an iso- 
lated injury it 
must be exceedingly rare, 
may also be involved. 

Fracture of the inframalleolar or trochlear process is also 
extremely rare. It is more apt to be produced by a direct 
injury splitting off the bony process, than by the action 
of the calcaneo-fibular ligament, as was formerly thought. 
The tendons of the peronei muscles may be injured. 




Fig. 158. — Fracture of the great toe. Wiese, 
male, thirty years old. Produced by a 100-pound 
weight falling on the foot. Fracture and abra- 
sion of the great toe, and fracture of the distal 
phalanx of the second toe. Ordinary dressing; 
recovery. The swelling, however, persisted for 
some time. 



The contiguous cuboid bone 



342 FRACTURES AND DISLOCATIONS. 

The treatment of these injuries should be carried out 
according to general principles. In every case the foot 
should remain fixed in its normal position for a consider- 
able length of time. 

[Helbing 2 reports and illustrates a most interesting case 
of tear-fracture of the os calcis. These are very rare 
fractures. Martens, 2 in reporting nine cases of fracture 
of the os calcis with excellent X-ray photographs, con- 
siders the entire subject, with some interesting experimental 
work in regard to compression-fractures. — Ed.] 

(c) Fractures of the Remaining Bones of the Tarsus. 
— Isolated fractures of the remaining bones of the tarsus 
are rare, and when recognized, should be treated by 
exposing the fragments by an incision and securing pro- 
longed rest of the foot by means of firm bandages. Later 
a brace should be worn. 

Fractures of the metatarsal bones are much commoner 
than was formerly supposed, as recent investigations by 
Kirchner and others have proved. By the help of the 
Rontgen-ray examination, it has been shown that the 
swelling of the foot which occurs after a trifling injury, 
" swelled foot," as the soldiers call it, is in many cases due 
to fracture of a metatarsal bone. It is astonishing to find 
out how small an injury to the foot, protected as it is by 
the boot, suffices to produce an isolated fracture of a meta- 
tarsal bone. The injury may consist in a blow against the 
sole of the foot, or in the long axis of the foot, as in 
marching, especially on frozen and uneven ground. The 
fracture is more often produced by direct violence, and is 
then complicated with injuries of the soft parts. In figures 
156, 157, and 158 several skiagraphs taken from cases of 
this kind are reproduced. 

Isolated fractures of the phalanges are rare. 

The treatment of all these fractures is based on general 
principles. 

1 Deut. Zeitschr. f. Chir., Bd. lviii, p. 489, 1901. 

2 Arch. f. klin. Chir., Bd. lxiv, 1901, p. 899. 



FRACTURES OF THE LOWER EXTREMITY. 343 

(B) Dislocations 

Dislocations in the tarsus, particularly at the so-called 
Lisfranc's articulation, are somewhat more common than 
was formerly supposed. In these cases examination by 
means of the Rontgen rays is of the greatest value and 
should never be neglected, especially in the initial period 
of the treatment, no matter how great the swelling may 
be, because the latter disappears very slowly and valuable 
time is lost before reduction is effected. 

(a) Dislocations of the tarsal bones are rare injuries, 
but more frequent than was formerly supposed. They 
comprise luxations of individual tarsal bones or of several 
bones in various combinations, not infrequently in the form 
of a subluxation. The diagnosis is made by careful pal- 
pation, but not until the swelling has subsided. This may 
be expedited by massage, elevation, and compression. By 
means of the Rontgen rays the examination may, of course, 
be made at once. Reduction may be extremely difficult and 
may require incision. In order to effect reduction it is jus- 
tifiable to exert every means to enlarge the opening through 
which the bone has escaped. The bone or bones, after re- 
duction, must be firmly fixed, if necessary by means of a 
bone suture or a nail. In old cases the treatment is merely 
palliative ; the wearing of a rigid sole made to correspond 
with a plaster-of-Paris cast, etc.; or partial or total extir- 
pation may be resorted to. 

(b) Dislocation of the metatarsal bones — that is, 
at the so-called Lisfranc's articulation — usually assumes 
the form of complete displacement of several or all of the 
metatarsal bones on the dorsum of the foot. The dorsum 
presents an abnormal bony prominence ; the foot has the 
form of a pes cavus and simulates talipes. Plantar dislo- 
cation is much more rare. Reduction is difficult ; each 
bone may have to be replaced separately. It may be suc- 
cessful in recent cases ; in an old case operative interven- 
tion becomes necessary. 



344 FRACTURES AND DISLOCATIONS. 

(c) Dislocation of the Toes. — This injury is similar 
to dislocation of the fingers, but is of course much less 
frequent. Upward dislocation of the phalanx is produced 
by forced dorsal flexion. The diagnosis is easy, and re- 
duction is readily effected by pushing the dorsally flexed 
(extended) phalanx forward. 



INDEX 



Acromial dislocations of clav- 
icle, 136 
diagnosis, 137 
treatment, 137 
Ankle, fractures of, 321 
Astragalo-crural articulation, 333 

dislocations at, 333 
Astragalo-tarsal articulation, dis- 
locations at, 334 
Astragalus, fractures of, 335 
isolated dislocation of, 334 

Backward dislocations of fore- 
arm, 187. See also Fore- 
arm, backward dislocations 

of. 
of humerus, 153 
of lower jaw, 107 
Base of skull, fractures of, 90 
course, 98 
escape of brain-matter in, 

97 
escape of cerebrospinal fluid 

in, 97 
hemorrhage in, 95 
injury to nerves at base of 

brain in, 97 
prognosis, 98 
symptoms, 95 
Bending fractures, 24 



Brain, injury to nerves at base of, 
in fractures of base of skull, 97 

Brain-matter, escape of, in frac- 
tures of base of skull, 97 

Carpal bones, fractures of, 228 
Carpo-metacarpal joints, disloca- 
tions at, 231 
Cerebrospinal fluid, escape of, in 

fracture of base of skull, 97 
Clavicle, acromial dislocations of, 
136 
diagnosis, 137 
treatment, 137 
dislocations of, 135 
fractures of, 127 
diagnosis, 129 
symptoms, 129 
treatment, 130 
sternal dislocations of, diagno- 
sis, 136 
treatment, 136 
Colles' fracture, 213 
cause, 216 
diagnosis, 220 
prognosis, 220 
symptoms, 217 
treatment, 220 
Comminuted fractures, 31 
Complete fractures, 21 



345 



346 



INDEX. 



Compound fractures, 18 
Compression-fractures, 29 

at upper end of tibia, 305 
Contusion-fractures, 29 
Cooper's method of reducing dis- 
location of humerus, 147 
Coronoid process of ulna, frac- 
tures of, 207 
symptoms, 208 
treatment, 208 
Costal cartilages, fractures of, 125 

Depressed fractures, 21 
Direct fracture, 22 
Dislocations, 77 

acromial, of clavicle, 136 
diagnosis, 137 
treatment, 137 
after-treatment of, 82 
at astragalo-crural articulation, 

333 
at astragalo-tarsal articulation, 

334 
at carpo-metacarpal joints, 231 
at interphalangeal joints, 238 
at lower articulation of ulna, 

227 
at metacarpal -phalangeal joints, 

232, 237 
at wrist- joint, 227 
backward, of forearm, 187. See 
also Forearm, backward dis- 
locations of. 
of hip-joint, 245 
symptoms, 247 
treatment, 249 
of humerus, 153 
central, of hip-joint, 253 
downward, of hip- joint, 253 
of humerus, 153 



Dislocations, forward, of forearm, 

193 
of hip-joint, 251 

diagnosis, 252 

treatment, 252 
of humerus, 139. See also 

Humerus, forward disloca- 
tions of. 
habitual, 82 

in thoracic and lumbar regions, 
122 
prognosis, 123 
intercarpal, 231 
isolated, of astragalus, 334 
of radius, 194 
of ulna, 194 
lateral, of forearm, 191. See also 
Forearm, lateral dislocations of. 
of clavicle, 135 
of elbow, 187 
of fingers, 231 
of hand, 231 
of hip-joint, 244 
of knee-joint, 287 
of lower extremity, 238 
of lower jaw, 105 

symptoms, 106 
of metatarsal bones, 343 
of patella, 289 
of ribs, 125 
of shoulder- joint, 139 
of tarsal bones, 343 
of thumb, 233 
of toes, 344 

of upper extremity, 126 
of vertebral column, 120 

prognosis, 121 

symptoms, 121 

treatment, 121 
old, 83 



INDEX. 



347 



Dislocations, sternal, of clavicle, 
135. See also Clavicle, sternal 
dislocations of. 
symptoms of, 79 
upward, of hip-joint, 253 
Dressings in fractures, 63 

Elbow, dislocations of, 187 
intraarticular injuries of, 195 

Facial bones, injuries of, 102 
Femur, articular extremity of, 
split fractures at, 287 
condyles of, oblique and T- 

fracture of, 287 
fractures of, 253 

in trochanteric region, 269 
lower end of, fractures of, 284 
traumatic epiphyseal sepa- 
ration at, 286 
neck of, fractures of, 256 
cause, 257 

morbid anatomy, 259 
symptoms, 261 
treatment, 266 
separation of a fragment from 
cartilaginous covering of end 
of, 302 
shaft of, fractures of, 271 
below trochanter, 269 
below trochanter, symp- 
toms, 270 
below trochanter, treat- 
ment, 271 
treatment of, 274 
supracondylar fracture of, 284 
upper end of, fractures of, 
253 
traumatic epiphyseal sepa- 
ration at, 268 



Fibula, isolated fractures at upper 
end of, 308 
lower end of, isolated fractures 

of, 332 
shaft of, isolated fractures of , 317 
Fingers, dislocations of, 231 

fractures of, 228 
Foot, dislocations of, 335 

fractures of, 335 
Forearm, backward dislocations 
of, 187 
diagnosis, 190 
method of reducing, 189 
prognosis, 191 
symptoms, 188 
treatment, 191 
forward dislocations of, 193 
fractures of, 196 
both bones of, 196 
prognosis, 198 
treatment, 199 
lateral dislocations of, 191 
prognosis, 193 
symptoms, 192 
treatment, 193 
Forward dislocations of lower 
jaw, 105 
of forearm, 194 
of humerus, 139. See also 
Humerus, forward disloca- 
tions of. 
Fractures, 17 

abnormal mobility in, 32 
after-treatment of, 74 
ambulatory method of treating, 

73 
bending, 24 
by muscular action, 31 
Colles', 213. See also Colles' 
fracture. 



348 



INDEX. 



Fractures, comminuted, 31 
complete, 21 
complications of, treatment of, 

49 
compound, 18 
compression-, 29 

of upper end of tibia, 305 
contusion-, 29 
crepitus io, 32 
course of, 43 
deformity in, 34 
depressed, 21 
diagnosis of, 42 
direct, 22 

disturbance of function in, 37 
dressing in, 63 
examination of, 37 

Eontgen rays in, 39 
extravasation of blood in, 35 
greenstick, 21, 24 
gunshot, 31 
impacted, 30 
incomplete, 21 
indirect, 22 

intra-articular, of humerus, 185 
isolated, at upper end of fibula, 
308 

of fibula, at lower extremity, 
332 

of greater or lesser tuberosity 
of humerus, 165 
treatment, 165 

of shaft of fibula, 317 

of shaft of tibia, 316 

of tibia, at lower extremity, 
332 
joint, treatment of, 74 
longitudinal, at lower end of 

humerus, 186 
mechanism of, 24 



Fractures, oblique and T-, of con- 
dyles of femur, 287 
of lower end of humerus, 181 
of anatomic neck of humerus, 
155 
symptoms, 156 
treatment, 157 
of ankle, 321 
of astragalus, 335 
of base of skull, 90 
course, 98 
escape of brain-matter in, 

97 
escape of cerebrospinal fluid 

in, 97 
hemorrhage in, 95 
injury to nerves at base of 

brain in, 97 
prognosis, 98 
symptoms, 95 
of both bones of forearm, 196 
prognosis, 198 
treatment, 199 
of both bones of leg at lower 
ends, 318 
in region of diaphysis, 
309 
treatment, 310 
of both malleoli, 330 
of carpal bones, 228 
of clavicle, 127 
diagnosis, 129 
symptoms, 129 
treatment, 130 
of condyles of lower end of 

humerus, 184 
of coronoid process of ulna, 207 
symptoms, 208 
treatment, 208 
of costal cartilages, 125 



INDEX. 



349 



Fractures of femur, 253 

in trochanteric region, 269 
of fingers, 228 
of foot, 335 
of forearm, 196 
of hand, 228 
of head of radius, 212 
of humerus, 154 
of leg, 305 

ambulatory treatment, 314 

at upper end, 305 

prognosis, 316 
of lower end of femur, 284 
of humerus, 171 

extremity, 238 

jaw, 103 

treatment, 104 

radial epiphysis, 213. See 
also Colles 1 fracture. 
of malar bones, 103 
of metacarpal bones, 228 
of metatarsal bones, 342 
of neck of femur, 256. Bee 

also Femur, neck of, fractures 
of., 
of neck of radius, 213 
of olecranon, 204 

prognosis, 205 

treatment, 206 
of os calcis, 336 
diagnosis, 337 
treatment, 338 
of patella, 290. See also Pa- 
tella, fractures of. 
of pelvis, 238 

complications in, 241 

prognosis, 242 

treatment, 242 
of radius, 212 
of ribs, 123 



Fractures of ribs, diagnosis, 123 
treatment, 124 
of scapula, 137 
of shaft of femur, 271 
below trochanter, 269 
symptoms, 270 
treatment, 271 
treatment, 274 
of humerus, 165 
treatment, 167 
of radius, 213 
of ulna, 211 
of skull, 84 

treatment, 101 
of skullcap, 85 
of sternum, 125 
diagnosis, 126 
treatment, 126 
of superior maxillary bone, 

103 
of surgical neck of humerus, 
157 
symptoms, 158 
treatment, 159 
of styloid process of ulna, 211 
of tarsal bones, 335, 342 
of thorax, 123 
of ulna, 204 

of upper end of femur, 253 
of humerus, 154 
extremity, 126 
third of ulna, with disloca- 
tion of head of radius, 209 
of vertebra, 109 
diagnosis, 113 
prognosis, 114 
symptoms, 111 
treatment, 116 
of vertebral column, 109, 120 
open, 18 



350 



INDEX. 



Fractures, pain in, 36 
Pott's, 321. See also PotVs 

fracture. 
prognosis, 59 
reduction in, 62 
repair of, 43 
simple, 18 
split, at articular extremity of 

femur, 287 
spontaneous, 17 
sprain-, 31 
subcutaneous, 18 
supracondylar, of femur, 284 
of lower end of humerus, 173 
symptoms, 174 
treatment, 177 
supramalleolar, of both bones 

of leg, 318 
symptoms of, 32 
tear-, of tuberosity of tibia, 308 
through tuberosities of hum- 
erus, 161 
torsion-, 28 

transverse, of true articular 
process of lower end of 
humerus, 179 
of true articular process of 
lower end of humerus, 
treatment, 180 
of upper extremity of tibia, 
306 
traumatic, 17 
treatment, 62 
ultimate result in, 38 
unfavorably united, treatment, 

75 
varieties of, 21 

Greenstick fractures, 21, 24 
Gunshot fracture, 31 



Habitual dislocations, 82, 152 
Hand, dislocations of, 231 

fractures of, 228 
Hemorrhage in fractures of base 

of skull, 95 
Hip-joint, backward dislocations 
of, 245 
symptoms, 247 
treatment, 249 
central dislocation of, 252 
dislocations of, 244 
downward dislocation of, 253 
forward dislocations of, 251 
diagnosis, 252 
treatment, 252 
upward dislocations of, 264 
Humerus, anatomic neck of, frac- 
tures of, 155 
symptoms, 156 
treatment, 151 
backward dislocations of, 153 
dislocations of, modifications 

and complications of, 152 
downward dislocations of, 153 
forward dislocations of, 139 
accessory injuries in, 146 
after-treatment, 149 
diagnosis, 146 
habitual dislocation after, 

152 
modifications and compli- 
cations of, 152 
old dislocation after, 152 
symptoms, 141 
treatment, 147 
fractures of, 154 
greater or lesser tuberosity of, 
fractures of, 165 
treatment, 165 
intra-articular fractures of, 185 



IXBEX. 



351 



Humerus, lower end of, fractures 
of, 171 
of condyles of, 184 
longitudinal fractures at, 

186 
oblique fractures of, 181 
supracondylar fractures of, 
173 
symptoms, 174 
treatment, 177 
transverse fracture of true 
articular process of, 179 
transverse fracture of true 
articular process of, 
treatment, 180 
shaft of, fractures of, 165 

treatment, 167 
surgical neck of, fractures of, 
157 
symptoms, 158 
treatment, 159 
tuberosities of, fractures 

through, 161 
upper end of, fractures of, 154 
traumatic epiphyseal sepa- 
ration at, 161 

Impacted fractures, 30 

Incomplete fractures, 21 

Indirect fractures, 22 

Injuries of facial bones, 102 
of nasal bones, 102 

Intercarpal dislocations, 231 

Interphalangeal joints, disloca- 
tions at, 238 

Intra-articular injuries of elbow, 
195 

Jaw, lower, dislocations of, 105 
symptoms, 106 



Jaw, fractures of, 103 
treatment, 104 
Joint fractures, treatment of, 74 

Knee-joint, dislocations of, 287 
semilunar cartilages of, injuries 
of, 303 
treatment, 305 
Koeher's method of reducing dis- 
location of humerus, 147 

Lateral dislocations of forearm, 
191. See also Forearm, lateral 
dislocations of. 
Leg, upper end, fracture of, 305 
epiphyseal separation at lower 

extremities of bones of, 331 
fractures of, 305 

ambulatory treatment, 314 
both bones of, at lower ends, 
318 
in region of diaphysis, 
309 
treatment, 310 
prognosis, 316 
Lumbar and thoracic regions, dis- 
locations in, 122 
prognosis, 123 

Malar bone, fractures of, 103 

Malleoli, fractures of, 330 

Maxillary bone, superior, frac- 
tures of, 103 

Metacarpal bones, fractures of, 
328 

Metacarpophalangeal joints, dis- 
locations at, 232, 237 

Metatarsal bones, dislocations of, 
343 

Muscular action, fracture by, 31 



352 



INDEX. 



Nasal bones, injuries of, 102 
Nerves at base of brain, injury to, 
in fracture of base of skull, 97 

Old dislocations, 83 
Olecranon, fractures of, 204 
prognosis, 205 
treatment, 206 
Open fractures, 18 
Os calcis, fracture of, 336 
diagnosis, 337 
treatment, 338 

Patella, dislocations at, 289 
fractures of, 290 

prognosis, 293 

symptoms, 293 

treatment, 295 
second fracture of, 300 
Pelvis, fractures of, 238 

complications in, 241 

prognosis, 242 

treatment, 242 
Pott's fracture, 321 

cause, 322 

prognosis, 326 

symptoms, 323 

treatment, 326 

Radius, fractures of, 212 
head of, fractures of, 212 
isolated dislocations of, 194 
lower end of, true epiphyseal 

separation of, 226 
lower epiphysis of, fractures of, 

213. See also Colles 1 fracture. 
neck of, fractures of, 213 
shaft of, fractures of, 213 
traumatic epiphyseal separation 

at upper end of, 213 



Reduction in fractures, 62 
Repair of fractures, 43 
Ribs, dislocations of, 125 
fractures of, 123 
diagnosis, 123 
treatment, 124 
Rontgen rays in examination of 
fractures, 39 

Scapula, fractures of, 137 
Semilunar cartilages of knee-joint, 
injuries of, 303 
treatment, 305 
Shoulder- joint, dislocations of, 

139 
Simple fractures, 18 
Skull, base of, fractures of, 90 
course, 99 

escape of brain-matter in, 97 
hemorrhage in, 95 
injury to nerves at base of 

brain in, 97 
prognosis, 98 
symptoms, 95 
fractures of, 84 
treatment, 101 
Skullcap, fractures of, 85 
Spontaneous fractures, 17 
Sprain-fracture, 31 
Sternal dislocations of clavicle. 
See also Clavicle, sternal disloca- 
tions of. 
Sternum, fractures of, 125 
diagnosis, 126 
treatment, 126 
Subcutaneous fractures, 18 
Supracondylar fractures of femur, 

284 
Supramalleolar fracture of both 
bones of the leg, 318 



INDEX. 



353 



Tarsal bones, dislocations of, 
343 
fractures of, 335, 342 
Tear-fracture of tuberosity of 

tibia-, 308 
Thoracic and lumbar regions, dis- 
locations in, 122 
prognosis, 123 
Thorax, fractures of, 123 
Thumb, dislocations of, 233 
Tibia, lower end of, isolated frac- 
tures at, 332 
shaft of, isolated fractures of, 

316 
tuberosity of, tear-fracture of, 

308 
upper end of, compression -frac- 
tures of, 305 
transverse fracture of, 306 
traumatic epiphyseal sepa- 
ration at, 307 
Toes, dislocations of, 344 
Torsion-fractures, 28 
Traumatic fractures, 17 

Ulxa, coronoid process of, frac- 
tures of, 207 
symptoms, 208 
treatment of, 208 



Ulna, fractures of, 204 

isolated dislocations of, 194 
lower articulation of, disloca- 
tion at, 227 
shaft of, fractures of, 211 
styloid process of, fractures of, 

211 
upper third of, fractures of, 
with dislocation of head of 
radius, 209 

Varieties of fracture, 21 
Vertebra, fractures of, 109 
diagnosis, 113 
prognosis, 114 
symptoms, 111 
treatment, 116 
longitudinal fractures of, 111 
oblique fractures of, 111 
transverse fractures of, 111 
Vertebral column, dislocations of, 
120 
prognosis, 121 
symptoms, 121 
treatment, 121 
fractures of, 109, 120 

Wrist-} oint, dislocations at, 227 



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text. Cloth, $3.50 net. 

ATLAS AND EPITOME OF THE NERVOUS SYSTEM AND ITS DISEASES. 

By Professor Dr. Chr. Jakob, of Erlangen. From the Second Revised and Enlarged 
German Edition. Edited, with additions, by Edward D. Fisher, M. D., Professor of 
Diseases of the Nervous System, University and Bellevue Hospital Medical College, 
N. Y. With 83 plates ; copious text. $3.50 net. 

ATLAS AND EPITOME OF LABOR AND OPERATIVE OBSTETRICS. 

By Dr. O. Schaeffer, of Heidelberg. From the Fifth Revised and Enlarged German 
Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of Obstetrics 
and Clinical Midwifery, Cornell University Medical School. With 126 colored illustra- 
tions. $2.00 net. 

ATLAS AND EPITOME OF OBSTETRICAL DIAGNOSIS AND TREATMENT. 

By Dr. O. Schaeffer, of Heidelberg. From the Second Revised and Enlarged Ger- 
man Edition. Edited, with additions, by J. Clifton Edgar, M. D., Professor of 
Obstetrics and Clinical Midwifery, Cornell University Medical School. 72 colored 
plates, numerous text-illustrations, and copious text. $3.00 net. 

ATLAS AND EPITOME OF OPHTHALMOSCOPY AND OPHTHALMOSCOPIC 
DIAGNOSIS. 

By Dr. O. Haab, of Zurich. From the Third Revised and Enlarged German Edi- 
tion. Edited, with additions, by G. E. de Schweinitz, M. D., Professor of Ophthal- 
mology, Jefferson Medical College, Philadelphia. With 152 colored figures and 82 
pages of text. Cloth, $3.00 net. 

ATLAS AND EPITOME OF BACTERIOLOGY. 

Including a Hand-Book of Special Bacteriologic Diagnosis. By Prof. Dr. K. B. 
Lehmann and Dr. R. O. Neumann, of Wiirzburg. From the Second Revised German 
Edition. Edited, with additions, by George H. Weaver, M. D., Assistant Professor 
of Pathology and Bacteriology, Rush Medical College. In Two Parts. Part I., con- 
sisting of 632 colored figures on 69 plates. Part II., consisting of 511 pages of text, 
illustrated. Per Part : Cloth, $2.50 net. 

ATLAS AND EPITOME OF OTOLOGY. 

By Dr. Gustav Bruhl, of Berlin, with the collaboration of Prof. Dr. A. Politzer, of 
Vienna. Edited, with additions, by S. MacCuen Smith, M. D., Clinical Professor of 
Otology, Jefferson Medical College, Phila. 244 colored figures on 39 plates, 99 text- 
cuts, and 292 pages of text. Cloth, $3.00 net. 

ATLAS AND EPITOME OF ABDOMINAL HERNIA. 

By Privatdocent Dr. Georg Sultan, of Gottingen. Edited, with additions, by Wil- 
liam B. Coley, Clinical Lecturer on Surgery, College of Physicians and Surgeons, New 
York. With 43 colored figures on 36 plates, 100 text-cuts, and about 250 pages of text. 
In Press. 

ATLAS AND EPITOME OF FRACTURES AND LUXATIONS. 

By Prof. Dr. H. Helferich, of Kiel. Edited, with additions, by Joseph C. Blood- 
good, Associate in Surgery, Johns Hopkins University, Baltimore. With 215 colored 
figures on 72 plates, 144 text-cuts, 42 skiagraphs, and over 300 pages of text. /// Press. 

ATLAS AND EPITOME OF DISEASES OF MOUTH, THROAT, AND NOSE. 

By Dr. L. Grunwald, of Munich. From the Second Revised and Enlarged German 
Edition. With 42 colored figures, 39 text-cuts, and 225 pages of text. 



ADDITIONAL VOLUMES IN PREPARATION 

17 



Nothnagel's Encyclopedia 

OF 

PRACTICAL MEDICINE. 

AMERICAN EDITION. 
Edited by ALFRED STENGEL, M.D., 

Professor of Clinical Medicine in the University of Pennsylvania ; Visiting 
Physician to the Pennsylvania Hospital. 

IT is universally acknowledged that the Germans lead the world in Internal Medicine ; 
and of all the German works on this subject, NothnageFs " Specielle Pathologie und 
Therapie " is conceded by scholars to be without question the best System of Medicine 
in existence. So necessary is this book in the study of Internal Medicine that it comes 
largely to this country in the original German. In view of these facts, Messrs. W. B. 
Saunders & Company have arranged with the publishers to issue at once an authorized 
American edition of this great encyclopedia of medicine. 

For the present a set of ten volumes, representing the most practical part of this 
excellent encyclopedia, and selected with especial thought of the needs of the practical 
physician, will be published. These volumes will contain the real essence of the entire 
work, and the purchaser will therefore obtain at less than half the cost the cream of the origi- 
nal. Later the special and more strictly scientific volumes will be offered from time to time. 

The work will be translated by men possessing thorough knowledge of both English and 
German, and each volume will be edited by a prominent specialist on the subject to 
which it is devoted. It will thus be brought thoroughly up to date, and the American edition 
will be more than a mere translation of the German ; for, in addition to the matter contained 
in the original, it will represent the very latest views of the leading American and 
English specialists in the various departments of Internal Medicine. The whole System 
will be under the editorial supervision of Dr. Alfred Stengel, who will select the subject: 
for the American edition, and will choose the editors of the different volumes. 

Unlike most encyclopedias, the publication of this work will not be extended over a 
number of years, but five or six volumes will be issued during the coming year, and the 
remainder of the series at the same rate. Moreover, each volume will be revised to the 
date of its publication by the eminent editor. This will obviate the objection that has 
heretofore existed to systems published in a number of volumes, since the subscriber will 
receive the completed work while the earlier volumes are still fresh. 

The usual method of publishers, when issuing a work of this kind, has been to compel 
physicians to take the entire System. This seems to us in many cases to be undesirable. 
Therefore, in purchasing this encyclopedia, physicians will be given the opportunity of 
subscribing for the entire System at one time ; but any single volume or any number of 
volumes may be obtained by those who do not desire the complete series. This latter 
method, while not so profitable to the publishers, offers to the purchaser many advan- 
tages which will be appreciated by those who do not care to subscribe for the entire work 
at one time. 

This American edition of Nothnagel's Encyclopedia will, without question, form the 
greatest System of Medicine ever produced, and the publishers are confident that it 
will meet with general favor in the medical profession. 

IS 



NOTHNAGEL'S ENCYCLOPEDIA. 

AMERICAN EDITION. 
VOLUMES JUST ISSUED AND IN PRESS. 

TYPHOID AND TYPHUS FEVERS. By Dr. H. Curschmann, of Leipsic. 

Editor, "William Osier, M.D., F.R.C.P., Professor of the Principles and Practice 
of Medicine in Johns Hopkins University, Baltimore. Handsome octavo, 646 pages, 
72 valuable text illustrations, and two lithographic plates. Cloth, $5.00 net; Half 
Morocco, $6.00 net. Just Ready. 

VARIOLA (including VACCINATION). By Dr. H. Immermann, of Basle. 
VARICELLA. By Dr. Th. von Jurgensen, of Tubingen. CHOLERA 
ASIATICA and CHOLERA NOSTRAS. By Dr. C. Liebermeister, of 
Tubingen. ERYSIPELAS and ERYSIPELOID. By Dr. H. Lenhartz, of 
Hamburg. PERTUSSIS and HAY-FEVER. By Dr. G. Sticker, of Giessen. 
Editor, Sir J. W. Moore, B.A., M.D., F.R.C.P.I., Professor of the Practice of 
Medicine, Royal College of Surgeons, Ireland. Handsome octavo of 682 pages, illus- 
trated. Cloth, $5.00 net ; Half Morocco, $6.00 net. Just Ready. 

DIPHTHERIA. By the editor. Measles, Scarlet Fever, Rotheln. By Dr. Th. von 
Jurgensen, of Tubingen. 

Editor, William P. Northrup, M. D. t Professor of Pediatrics, University and Belle- 
vue Medical College, N. Y Handsome octavo, 700 pages, illustrated. Cloth, $5.00 
net ; Half Morocco, 36.00 net. Just Ready. 

DISEASES OF THE BRONCHI. By Dr. F. A. Hoffmann, of Leipsic. DIS- 
EASES OF THE PLEURA. By Dr. O. Rosenbach, of Berlin. PNEU- 
MONIA. By Dr. E. Aufrecht, of Magdeburg. 

Editor, John H. Musser, M. D., Professor of Clinical Medicine, University of Penn- 
sylvania. Handsome octavo, 700 pages, 7 full-page lithographs in colors. Cloth, $5.00 
net ; Half Morocco, $6.00 net. Just Ready. 

INFLUENZA AND DENGUE. By Dr. O. Leichtenstern, of Cologne. MALA- 
RIAL DISEASES. By Dr. J. Mannaberg, of Vienna. 

Editor, Ronald Ross, F.R.C.S., Eng., D.P.H., F.R.S., Major, Indian Medical 
Service, retired; Walter Myers Lecturer, Liverpool School of Tropical Medicine. 
Handsome octavo, 700 pages, 7 full-page lithographs in colors. 

ANEMIA, LEUKEMIA, PSEUDOLEUKEMIA, HEMOGLOBINEMIA. By 

Dr. P. Ehrlich, of Frankfort-on-the-Main, Dr. A. Lazarus, of Charlottenburg, and 
Dr. Felix Pinkus, of Berlin. CHLOROSIS. By Dr. K. von Noorden, of 
Frankfort-on-the-Main. 

Editor, Alfred Stengel, M.D., Professor of Clinical Medicine, University of Pennsyl- 
vania. Handsome octavo, 750 pages, 5 full-page lithographs in colors. 

TUBERCULOSIS AND ACUTE GENERAL MILIARY TUBERCULOSIS. 

By Dr. G. Cornet, of Berlin. 

Editor to be announced later. Handsome octavo, 700 pages. 

DISEASES OF THE STOMACH. By Dr. F. Riegel, of Giessen. 

Editor, Charles G. Stockton, M.D., Professor of Medicine, University of Buffalo. 
Handsome octavo, 800 pages, with 29 text-cuts and 6 full-page plates. 

DISEASES OF THE LIVER. By Drs. H. Quincke and G. Hoppe-Seyler, of 
Kiel. DISEASES OF THE PANCREAS. * By Dr. L. Oser, of Vienna. DIS- 
EASES OF THE SUPRARENALS. By Dr. E. Neusser, of Vienna. 
Editors, Frederick A. Packard, M.D., Physician to the Pennsylvania and to the 
Children's Hospitals, Philadelphia; and Reginald H. FitZ, A.M., M.D., Hersey 
Professor of the Theory and Practice of Physic, Harvard University. 

DISEASES OF THE INTESTINES AND PERITONEUM. By Dr. Hermann 

Nothnagel, of Vienna. 

Editor, Humphry D. Rolleston, M.D., F.R.C.P., Physician to and Lecturer on 
Pathology at St. George's Hospital, London. Handsome octavo, 800 pages, finely 
illustrated. 

19 



CLASSIFIED LIST 

OF THE 

MEDICAL PUBLICATIONS 



W. B. Saunders & Company. 



ANATOMY, EMBRYOLOGY, HIS- 
TOLOGY. 

Bohm, Davidoff, and Huber — A Text- 
Book of Histology, 4 

Clarkson — A Text-Book of Histology, t . 5 

Haynes — A Manual of Anatomy, . . ' . 7 

Heisler — A Text-Book of Embryology, . 8 

Leroy — Essentials of Histology, .... 15 
McClellan — Anatomy in Relation to 

Art; Regional Anatomy, 10 

Nancrede — Essentials of Anatomy, ... 15 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, .... 10 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, .... 15 

Frothingham — Laboratory Guide, ... 6 

Gorham — Laboratory Bacteriology, . . 7 
Lehmann and Neumann — Atlas of 

Bacteriology, 17 

Levy and Klemperer's Clinical Bacte- 
riology, . 9 

Mallory and Wright— Pathological 

Technique, 9 

McFarland— Pathogenic Bacteria, ... 10 

CHARTS, DIET-LISTS, ETC. 

Griffith — Infant's Weight Chart, .... 7 

Keen — Operation Blank, 9 

Laine — Temperature Chart, 9 

Meigs — Feeding in Early Infancy, ... 10 

Starr — Diets for Infants and Children, . 13 

Thomas — Diet-Lists, 14 

CHEMISTRY AND PHYSICS. 

Brockway — Ess. of Medical Physics, . 15 

Jelliffe and Diekman — Chemistry, . . 22 

Wolf — Examination of Urine, 14 

Wolff— Essentials of Medical Chemistry, 15 

CHILDREN. 

An American Text-Book of Diseases 

of Children, 1 

Griffith— Care of the Baby, 7 

Griffith — Infant's Weight Chart, .... 7 

Meigs — Feeding in Early Infancy, ... 10 

Powell — Essentials of Dis. of Children, 15 

Starr — Diets for Infants and Children, . 13 

DIAGNOSIS. 

Cohen and Eshner— Essentials of Diag- 
nosis, 15 

Corwin — Physical Diagnosis, 5 

Vierordt — Medical Diagnosis, 14 

DICTIONARIES. 

The American Illustrated Medical 

Dictionary, 3 

The American Pocket Medical Dic- 
tionary, 3 

Morton — Nurses' Dictionary, 10 



EYE, EAR, NOSE, AND THROAT. 

An American Text-Book of Diseases 

of the Eye, Ear, Nose, and Throat, . . 1 
Briihl and Politzer — Atlas of Otology, 17 
De Schweinitz — Diseases of the Eye, . 6 
Friedrich and Curtis— Rhinology, Lar- 
yngology, and Otology, 6 

Gleason— Essentials of the Ear, .... 15 
Gleason— Essentials of Nose and Throat, 15 
Gradle — Ear, Nose, and Throat, .... 7 
Grunwald— Atlas of Mouth, Throat, and 

Nose, 17 

Grunwald and Grayson — Atlas of Dis- 
eases of the Larynx, 16 

Haab and de Schweinitz— Atlas of Ex- 
ternal Diseases of the Eye, 16 

Jackson — Manual of Diseases of the Eye, 8 
Jackson — Essentials Diseases of Eye, . 15 
Kyle — Diseases of the Nose and Throat, 9 

GENITO-URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 2 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 8 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . . 15 

Mracek and Bangs — Atlas of Syphilis 
and the Venereal Diseases, 16 

Saundby — Renal and Urinary Diseases, ix 

Senn — Genito-Urinary Tuberculosis, . . 12 

Vecki — Sexual Impotence, 14 

GYNECOLOGY, 

American Text-Book of Gynecology, . 2 
Cragin — Essentials of Gynecology, ... 15 
Garrigues — Diseases of Women, . ... 7 
Long — Syllabus of Gynecology, .... 9 

Penrose — Diseases of Women, it 

Schaeffer and Norris — Atlas of Gyne- 
cology, 17 

HYGIENE. 

Abbott — Hygiene of Transmissible Dis- 
eases, 3 

Bergey — Principles of Hygiene, .... 4 
Pyle — Personal Hygiene, 11 

MATERIA MEDICA, PHARMA- 
COLOGY, and THERAPEUTICS. 
An American Text-Book of Applied 

Therapeutics, 1 

Butler — Text-Book of Materia Medica, 

Therapeutics, and Pharmacology, . . 5 
Morris — Ess. of M. M. and Therapeutics, 15 
Saunders' Pocket Medical Formulary, . 12 
Sayre — Essentials of Pharmacy, .... 15 
Sollmann — Text-Book of Pharmacology, 12 
Stevens — Modern Therapeutics, .... 13 
Stoney — Materia Medica for Nurses, . . 13 
Thornton — Prescription-Writing, ... 14 



MEDICAL PUBLICATIONS 



21 



MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

Chapman— Medical Jurisprudence and 
Toxicology 5 

Crothers — Morphinism, 5 

Golebiewski and Bailey— Atlas of Dis- 
eases Caused by Accidents, 17 

Hofmann and Peterson— Atlas of Legal 
Medicine, - 16 

NERVOUS AND MENTAL DIS- 
EASES, ETC. 

Brower — Manual of Insanity, 4 

Chapin — Compendium of Insanity, ... 5 
Church and Peterson — Nervous and 5 

Mental Diseases, 5 

Jakob and Fisher — Atlas of Nervous 

System, 17 

Shaw — Essentials of Nervous Diseases 

and Insanity, 15 

NURSING. 
Davis — Obstetric and Gynecologic Nurs- 
ing, 6 

Griffith— The Care of the Baby, .... 7 

Meigs — Feeding in Early Infancy, . . . iu 

Morten — Nurses' Dictionary, 10 

Stoney — Materia Medica for Nurses, . . 13 

Stoney — Practical Points in Nursing, . . 13 

Stoney — Surgical Technic for Nurses, . 13 

Watson — Handbook for Nurses, .... 14 

OBSTETRICS. 

An American Text-Book of Obstetrics, 2 
Ashton — Essentials of Obstetrics, 
Boisliniere — Obstetric Accidents 
Dorland— Modern Obstetrics, . 
Hirst— Text-Book of Obstetrics, 
Norris — Syllabus of Obstetrics, . 
Schaeffer and Edgar— Atlas of Obstet- 
rical Diagnosis and Treatment, .... 17 

PATHOLOGY. 

An American Text-Book of Pathology, 2 
Durck— Atlas of Pathologic Histology, 16 
Kalteyer — Essentials of Pathology, . . 22 
Mallory and Wright— Pathological 

Technique, 9 

Senn — Pathology, and Surgical Treat- 
ment of Tumors, 12 

Stengel— Text-Book of Pathology, ... 13 
Warren— Surgical Pathology, .... 14 

PHYSIOLOGY. 

American Text-Book of Physiology. . 2 

Raymond — Text-Book of Physiology, . n 

Stewart — Manual of Physiology, ... 13 

PRACTICE OF MEDICINE. 

An American Year-Book of Medicine 

and Surgery, 3 

Anders — Practice of Medicine, 4 

Eichhorst— Practice of Medicine, ... 6 

Lockwood — Practice of Medicine, ... 9 

Morris— Ess. of Practice of Medicine, . 15 

Nothnagel's Encyclopedia, . . . , 18, 19 

Salinger & Kalteyer— Mod. Medicine, ti 

Stevens— Practice of Medicine, ... 13 



SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 2 

Hyde and Montgomery— Syphilis and 

the Venereal Diseases, 8 

Martin— Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . . 15 

Mracek and Stelwagon— Atlas of Dis- 
eases of the Skin, 16 

Stelwagon — Diseases of the Skin, ... 22 

Stelwagon — Ess. of Diseases of Skin, . 15 

SURGERY. 

An American Text-Book of Surgery, . 2 
An American Year-Book of Medicine 

and Surgery, 3 

Beck — Fractures, 4 

Beck — Manual of Surgical Asepsis . . 4 

Da Costa — Manual of Surgery, .... 6 

Helferich — Atlas of Fractures 17 

International Text-Book of Surgery, 8 

Keen — Operation Blank, 9 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 8 

Macdonald — Surgical Diagnosis and 

Treatment, 9 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . . 15 

Martin — Essentials of Surgery, 15 

Moore — Orthopedic Surgery, 10 

Nancrede — Principles of Surgery, ... 10 

Pye — Bandaging and Surgical Dressing, 11 

Scudder — Treatment of Fractures, ... 12 

Senn— Genito-Urinary Tuberculosis, . . 12 

Senn — Practical Surgery, 12 

Senn — Syllabus of Surgery, 12 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 12 

Sultan — Atlas of Abdominal Hernia, . . 17 
Warren — Surgical Pathology and Ther- 
apeutics, 14 

Zuckerkandl and Da Costa— Atlas of 

Operative Surgery, . 16 

URINE AND URINARY DISEASES. 

Ogden — Clinical Examination of the 

Urine, n 

Saundby — Renal and Urinary Diseases, 11 

Wolf— Handbook of Urine Examination, 14 

Wolff— Examination of Urine, 15 

MISCELLANEOUS. 

Abbott — Hygiene of Transmissible Dis- 
eases, 3 

Bastin — Laboratory Exercises in Bot- 
any, 4 

Golebiewski and Bailey— Atlas of Dis- 
eases Caused by Accidents, . . . . 17 
Gould and Pyle — Anomalies and Curi- 
osities of Medicine, . . . .• 7 

Grafstrom— Massage, 7 

Keating— Examination for Life Insur- 
ance, 8 

Pyle — A Manual of Personal Hygiene, . 11 

Saunders' Medical Hand- Atlases, . 16, 17 

Saunders' Pocket Medical Formulary, . X2 

Saunders' Question-Compends, . . 14, 15 
Stewart and Lawrence— Essentials of 

Medical Electricity, 15 

Galbraith — The Four Epochs of Wo- 
man's Life, 7 



BOOKS IN PREPARATION. 



JELLIFFE AND DIEKMAN'S CHEMISTRY. 

A Text-Book of Chemistry. By Smith Ely Jelliffe, M. D., Ph. D., 
Professor of Pharmacology, College of Pharmacy, New York ; and 
George C. Diekman, Ph.G., M. D., Professor of Theoretical and Ap- 
plied Pharmacy, College of Pharmacy, New York. Octavo, 550 pages, 
illustrated. Ready Shortly. 

STELW AGON'S DISEASES OF THE SKIN. 

Diseases of the Skin. By Henry W. Stelwagon, M. D., Clinical Pro- 
fessor of Dermatology, Jefferson Medical College, Philadelphia. Royal 
octavo, 800 pages, fully illustrated. Ready Shortly. 

KALTEYER'S PATHOLOGY. 

Essentials of Pathology. By F. J. Kalteyer, M. D., Assistant in 
Clinical Medicine, Jefferson Medical College ; Pathologist to the Lying- 
in Charity Hospital, etc. In Saunders' Question- Compend Series. Ready 
Shortly. 

AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND 
TOXICOLOGY. 

Edited by Frederick Peterson, M. D., Chief of Clinic, Nervous Depart- 
ment, College of Physicians and Surgeons, New York ; and Walter S. 
Haines, M. D., Professor of Chemistry, Pharmacy, and Toxicology, 
Rush Medical College, Chicago. In Press. 

STENGEL AND WHITE ON THE BLOOD. 

The Blood in its Clinical and Pathological Relations. By Alfred Sten- 
gel, M. D., Professor of Clinical Medicine, University of Pennsylvania ; 
and C. Y. White, Jr., M. D., Instructor in Clinical Medicine, University 
of Pennsylvania. In Press. 

SULTAN'S ATLAS OF ABDOMINAL HERNIA. 

Atlas and Epitome of Abdominal Hernia. By Privatdocent Dr. 
Georg Sultan, of Gottingen. Edited, with additions, by William 
B. Coley, Clinical Lecturer on Surgery, College of Physicians and Sur- 
geons, New York. With 43 colored figures on 36 plates, 100 text-cuts, 
and about 250 pages of text. In Saunders" Hand-Atlas Series. 

HELFERICH'S ATLAS OF FRACTURES. 

Atlas and Epitome of Fractures and Luxations. By Prof. Dr. H. 
Helferich, of Kiel. Edited, with additions, by Joseph C. Blood- 
good, Associate in Surgery, Johns Hopkins University, Baltimore. 
With 215 colored figures on 72 plates, 144 text-cuts, 42 skiagraphs, 
and over 300 pages of text. In Saunders' Hand- Atlas Series. 

22 



AUG 1 1 1902 






L 
G. II 1302 



AUG. 15 190 






VOLUMES NOW READY. 

Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr. Chr. 

Jakob, of Erlangen. Edited by Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. With 179 colored figures on 68 plates and 
259 pages of text. Cloth, $3.00 net. 

Atlas of Legal Medicine. By Dr. E. von Hofmann, of Vienna. Edited by Fred- 
erick Peterson, M.D., Chief of Clinic, Nervous Department, College of Physicians 
and Surgeons, New York. With 120 colored figures on 56 plates and 193 half-tone 
illustrations. Cloth, $3.50 net. 

Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. 
Edited by Charles P. Grayson, M.D., Physician-in-Charge, Throat and Nose 
Department, Hospital of the University of Pennsylvania. With 107 colored figures 
on 44 plates, 25 text-illustrations, and 103 pages of text. Cloth, $2.50 net. 

Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. 
Edited by J. Chalmers DaCosta, M.D., Professor of the Practice of Surgery and 
Clinical Surgery, Jefferson Medical College, Philadelphia. With 24 colored plates, 
217 illustrations in the text, and 395 pages of text. Cloth, $3.00 net. 

Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. Dr. Franz 
Mracek, of Vienna. Edited by L. Bolton Bangs, M.D., Professor of Genito- 
urinary Surgery, University and Bellevue Hospital Medical College, New York. 
With 71 colored plates and 122 pages of text. Cloth, $3.50 net. 

Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zurich. 
Edited by G. E. de Schweinitz, M.D., Professor of Ophthalmology, Jefferson 
Medical College, Philadelphia. With 76 colored illustrations on 40 plates and 228 
pages of text. Cloth, $3.00 net. 

Atlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek, of Vienna. 
Edited by Henry W. Stelwagon, M.D., Clinical Professor of Dermatology, Jeffer- 
son Medical College, Philadelphia. With 63 colored plates, 39 half-tone illustrations, 
and 200 pages of text. Cloth, $3.50 net. 

Atlas and Epitome of Special Pathologic Histology. By Dr. H. Durck, of Munich. 
Edited by Ludvig Hektoen, M.D., Professor of Pathology, Rush Medical College, 
Chicago. In two parts. Part I. with 124 colored figures on 62 plates and 158 pages of 
text. Part II. with 120 colored figures on 60 plates and 192 pages of text. Price per 
part, $3.00 net. 

Atlas and Epitome of Diseases Caused by Accidents. By Dr. Ed. Golebiewski, 
of Berlin. Translated and edited, with additions, by Pearce Bailey, M.D., 
Attending Physician to the Almshouse and Incurable Hospitals, New York. With 
71 colored illustrations on 40 plates, 143 text-illustrations, and 549 pages of text. 
Cloth, $4.00 net. 

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidelberg. From 
the Second Revised and Enlarged German Edition. Edited by Richard C. Nor- 
ris, A.M., M.D., Gynecologist to the Methodist Episcopal and Philadelphia Hospi- 
tals. With 207 colored illustrations on 90 plates, 65 text-illustrations, and 308 pages 
of text. Cloth, $3.50 net. 

Atlas and Epitome of Labor and Operative Obstetrics. By Dr. 0. Schaffer, of 

Heidelberg. Front the Fifth Revised German Edition. Edited by J. Clifton Edgar, 
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Medical 
School. With 14 lithographic plates in colors and 139 other illustrations. Cloth, $2.00 net. 

Atlas and Epitome of Obstetrical Diagnosis and Treatment. By Dr. O. Schaffer, 
of Heidelberg. From the Second Revised German Edition. Edited by J. Clifton 
Edgar, M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University Med- 
ical School. With 122 colored figures on 56 plates, 38 other illustrations, and 317 pages 
of text. Cloth, $3.00 net. 

Atlas and Epitome of the Nervous System and its Diseases. By Prof. Dr. Chr. 
Jakob, of Erlangen. From the Second Revised German Edition. Edited by Edward 
D. Fisher, M. D., Professor of Diseases of the Nervous System, University and Bellevue 
Hospital Medical College, New York. With 83 plates and 215 pages of text. Cloth, 
$3.50 net. 

Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic Diagnosis. By 

Dr. O. Haab, of Zurich. From the Third Enlarged German Edition. Edited by G. 
E. de Schweinitz, M.D., Professor of Ophthalmology, Jefferson Medical College, 
Philadelphia. 152 colored figures and 82 pages of text. Cloth, $3.00 net. 

Atlas of Bacteriology and Text=Book of Special Bacteriologic Diagnosis. By 

Prof. Dr. K. B. Lehmann and Dr. R. O. Neumann, of Wurzburg. From the Second 
Revised German Edition. Edited by George H. Weaver, M. D., Assistant Professor 
of Pathology and Bacteriology, Rush Medical College, Chicago. Two volumes, with 
over 600 colored lithographic figures, and 500 pages of text. 

ADDITIONAL VOLUMES IN PREPARATION. 

W* B, SAUNDERS & CO-, Publishers, 
PHILADELPHIA* LONDON. 



